201801Visitor Requesting Accommodations
|VISITOR REQUESTING ACCOMMODATIONS |
|THIS SECTION TO BE COMPLETED BY VISITOR: Completed form is Confidential due to Personally Identifiable Information (PII) |PHYSICIAN : Please return form to |
|and Protected Health Information (PHI). PRINT LEGIBLY |(facility to fill in the information, |
| |before issue) |
| | |
|NAME (First, MI, Last) |DATE OF BIRTH |PHONE NUMBER (Include Area Code) |SEX |
| | | |Male |
| | | |Female |
|STREET ADDRESS |CITY/TOWN |STATE |ZIP CODE |
| | | | |
|REASON FOR VISIT (check appropriate box) | Inmate Visitor | Volunteer | Contractor | Vendor |
|NAME OF PERSON TO BE VISITED (If Applicable) |DOC NUMBER (If Applicable) |
| | |
|TYPE OF ACCOMMODATION BEING REQUESTED (e.g. wheelchair, walker, walking cane, oxygen equipment, Metal Detector Waiver etc.) |
| |
|NAME OF PHYSICIAN |PHYSICIAN’S PHONE NUMBER (Include Area Code) |
| | |
|THIS SECTION TO BE COMPLETED BY LICENSED PHYSICIAN |
|NOTE TO PHYSICIAN: YOU WILL BE CONTACTED FOR VERIFICATION OF INFORMATION PROVIDED |
|NAME |LICENSE NUMBER |PHONE NUMBER (Include Area Code) |
| | | |
|NAME OF CLINIC OR HOSPITAL |
| |
|STREET ADDRESS |CITY/TOWN |STATE |ZIP CODE |
| | | | |
|MEDICAL CONDITION REQUIRING ACCOMMODATION |
| |
|PHYSICIAN SIGNATURE |DATE SIGNED |
|TIME LIMIT OF NEEDED ACCOMMODATION |
|Permanent Temporary End Date of Temporary Accommodation |
|THIS SECTION TO BE COMPLETED BY INVESTIGATOR |
|NAME |TITLE |
| | |
|INVESTIGATOR COMMENTS |
| |
| Information Verified | Information NOT Verified |DATE(S) OF CONTACT |NAME OF WHO WAS CONTACTED |
|Recommend Approval |Recommend Denial | | |
|THIS SECTION TO BE COMPLETED BY SECURITY DIRECTOR/DESIGNEE |
| Denied for Accommodation | Approval for Accommodation | Approval for Temporary Detection Waiver to End on: |
| | | |
| Denied for Metal Detection Waiver | Approval for Metal Detection Waiver | |
|SECURITY DIRECTOR COMMENTS |
| |
|SECURITY DIRECTOR’S SIGNATURE |DATE SIGNED |
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