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Request for Accommodation by Person with a Disability

If you require an accommodation under the Americans with Disabilities Act (ADA) for a program or service, it is recommended that you make your request at least two weeks in advance in order to allow the court time to review your request and make arrangements for the accommodation. All requests for accommodation, regardless of timeliness, will be given due consideration and if necessary, may require an interactive process between the requester and the court to determine the best course of action. If your request is non-ADA related, please visit our website at www.courts.state.co.us for further instructions. If you need assistance in filling out this form, please contact the Jury Commissioner or ADA Coordinator. When you are done completing this form, please hit the "submit" button below and it will be forwarded to the appropriate judicial district. You will be notified by email once a decision is made on your request. Additional information may be needed to process your ADA request.

Genetic Information Nondiscrimination Act or 2008 Compliance:
When filling out this form, do not provide any genetic information which is defined to mean: information about the individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive.

NOTE: If you DO NOT HAVE AN EMAIL ADDRESS you can download a manual copy of the ADA request form.

Please provide the following information. Fields with an asterisk (*) are required.

* Requestor:
Juror Number:
* First Name:
* Last Name:
* Email Address:
* Phone Number:
Street Address:
City:
State/Zip:
* County of Filing:
* Court Type:
Proceeding Type:
Service/Program Type:
Case Name & Number:
Date Submitted:

Dates, Times, and Location when accommodations are needed.

Please describe the physical or mental limitation necessitating accommodation.

Please explain the type of accommodation(s) requested and any special requests or anticipated problems. Primary consideration will be given to the requested accommodation; however, the Colorado Judicial Department reserves the right to offer an alternative accommodation if one is more readily available and equally effective in accommodating your needs.

Additional information may be needed to process your ADA request.

I attest that the above information is true to the best of my knowledge and authorize this ADA request to be submitted.

YES, I agree.

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