Public Effective Communication Request Form

* Event Name:

* Date for When Auxiliary Aid or Service is needed:

* Location of Where Auxiliary Aid or Service is needed:

* Name of individual with a disability:

* Email:

Please enter a valid email

* Nature of Disability:

Blind

Low-Vision

Deaf

Hard of Hearing

Speech Impairment

Other:

Name of companion (if applicable):

Relationship to individual with a disability:

Family member

Friend

Other:

Contact information for individual with a disability (or other person, if applicable):

* Does the person with a disability want a qualified interpreter or an oral interpreter?

Yes. Choose one (free of charge):

American Sign Language (ASL)

Signed English

Oral interpreter

Other (explain):

No.

* Which of the following would be helpful for the person with a disability (free of charge)?

Videophone

Assistive listening device (sound amplifier)

Qualified note-taker

Qualified reader

Writing back and forth

Other:

ADA complaints, including those related to this policy, regarding areas associated with the 2010 Standards shall be immediately directed to the Harris County Clerk's Office Elections Department ADA Coordinator. The Disability Complaint Form is accessible online at www.harrisvotes.com for electronic submissions. Each voting center has also been provided a written Disability Complaint Form, if a complaint arises at any of the voting entities. The ADA Coordinator shall acknowledge and follow the procedures outlined in the grievance procedure to address the complaint and any appeals. The procedures are available at www.harrisvotes.com.