Documenting Efforts to Ensure Access

ADA Statistical Data Summary

District Court

. . . .

Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied

District Court TOTALS 0 0 0 0 . 0 0 0 0 0 0 0 0 . 0 0 0 0

Combined Mental and Physical . . . .

Combined Workforce, Public Users

Circuit Court

. . . .

Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied

Circuit Court TOTALS 0 0 0 0 . 0 0 0 0 0 0 0 0 . 0 0 0 0Combined

Mental and Physical . . . .

Combined Workforce, Public Users

Court of Special Appeals

. . . .

Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied

CoSA TOTALS 0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0Combined

Mental and Physical . . . .

Combined Workforce, Public Users

Court of Appeals

. . . .

Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied

CoA TOTALS 0 0 0 0 . 0 0 0 0 0 0 0 0 . 0 0 0 0Combined

Mental and Physical . . . .

Combined Workforce, Public Users

AOC

. . . .

Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied Granted Denied

AOC TOTALS 0 0 0 0 . 0 0 0 0 0 0 0 0 . 0 0 0 0Combined

Mental and Physical . . . .

Combined Workforce, Public Users

Court-Related Agencies

0 0 0 0

0 0

0 0

0 0 0 0

0 0

0 0

0 0 0 0

0 0

0 0

0

0 0 0 0

0 0

0 0

Physical

0 0 0

Physical Mental Physical Mental Physical

ADA Statistical Data

Workforce

Mental

0 0

Physical Mental Physical

0 0

Mental Physical

0 0

Mental Physical

0

Physical Mental Physical

0

0 0

Mental Physical

FY 2015

Total Employees =

Mental Physical

Workforce Public Users WorkForce Public Users

Mental Physical Mental Physical

0 0 0 0

WorkForce Public UsersPublic Users

0

0 0

0 0

0 0

0

Workforce

WorkForce Public Users

Public Users WorkForce Public Users

Mental Physical Mental

Public UsersWorkforce

FY 2014

Total Judicial Employees =

Mental Physical

Mental Physical Mental

0 0 0 0

Workforce

Mental Physical Mental

0

Mental Physical Mental Physical

0

WorkForce Public UsersPublic Users

Employee – Request for Accommodation

Form OFP – 201 (June 2012)

REQUEST FOR ACCOMMODATION

Employee/Applicant

Employee/Applicant’s Name:

Position:

Address: City/State:

Zip Code:

Work Location:

Work Telephone:

Date of Request for Accommodation:

Accommodation Request Please print or type. Be as specific as possible. If required, attach additional comments.

1. Request for an accommodation is received. The interactive process (simply talking to the employee about the accommodation requested) begins. 2. Provide employee with a copy of his/her PDQ/Job Description and a Medical Inquiry form. The job description is essential for the health care provider to review in concert with the completion of the Medical Inquiry form. 3. Review the request and the medical inquiry form to determine if there is a connection between the accommodation requested and the medical issue presented. 4. Will the requested accommodation help the employee to perform his/her job; is there an alternate accommodation that could be discussed.

Questions? Call us. The attached documentation provided by my health care provider certifies the need for the requested accommodation. Employee/Applicant’s Signature: ________________________________________ Date: ___________________

For Office Use Only

Date Request Received:___________________ Action Taken:________________________________________________________________________________ ________________________________________________________________________________ Administrative Official’s Signature: _______________________________________ Date: ___________________ Copy to: ADA Coordinator Office of Fair Practices

Employee – MedicalInquiryform

Employee Complaint of Discrimination/Retaliation: Physical or Mental Disability

State of Maryland Judiciary Complaint of Discrimination/Retaliation Form

Complainant: ______________________________________________________________________

(The employee making the complaint)

Location: _________________________________________________________________________ (Court Address)

Department/Unit: ___________________________________________________________________ Respondent: ______________________________________________________________________

(The employee against whom the complaint is made)

Location: _________________________________________________________________________ (Court Address)

Department/Unit: ___________________________________________________________________

STATEMENT OF FACTS Basis for the alleged discrimination, harassment, and /or retaliation (Please check applicable box(es)

Race Color National Origin Marital Status Sexual Orientation

Gender Political or Religious Opinion/Affiliation Physical or Mental Disability Age

Date(s) of Action(s)/Knowledge of Occurrence: ___________________________________________ Nature Complaint: (State specifically and definitely the issues of fact and the factor(s) that the employee believes would support the complaint)

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

(Please attach additional sheets if needed)

Remedy sought: ___________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Public Users of the Court

Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Specific case-related questions (e.g. postponements) should not be made on this form.

COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR

City/County

Located at Court Address

STATE OF MARYLAND or

Case No.

vs. Plaintiff/Petitioner Defendant/Respondent

REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested.

Name of Applicant:

Applicant is: Party Witness Juror Attorney Family Member or Guardian of a Victim

Victim Other

Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows:

1. Type of court proceeding: Criminal Civil Traffic Juvenile Other:

2. Hearing/Trial date: Time:

3. Nature of disability related impairment (specify):

4. Type of accommodation(s) requested. Be specific:

[Note - If requesting a sign language interpreter, specify type: American Sign Language interpreter (ASL), Certified Deaf Interpreter (CDI), or Communication Access Real Time Translation (CART). If requesting a spoken language interpreter, please use form CC-DC 41.]

5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify):

I request that this information be kept confidential to the extent allowed by law.

I certify that to the best of my knowledge this information is true and correct. I agree to provide medical documentation if required by the court.

Date Signature of Applicant/Applicant's Representative

Applicant/Applicant's Representative's Address Telephone No.

The clerk's office and the ADA Coordinator are available to provide further assistance.

The request for accommodation is GRANTED; or

Alternate accommodation(s) GRANTED (specify):

Date

The request for accommodation is DENIED.

Applicant does not qualify under the ADA.

It fundamentally alters the nature of the service program or activity as defined by the ADA. It creates an undue burden on the court as defined by the ADA.

Judge/Administrative Official

If you disagree with this decision, you can file a Grievance. (Form CC-DC 50 is available for this purpose.)

CC-DC 49 (Rev. 12/2012)

Court is usually notified 30 days in

advance of hearing.

Juror’s Requests

Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Specific case-related questions (e.g. postponements) should not be made on this form.

COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR

City/County

Located at Court Address

STATE OF MARYLAND or

Case No.

vs. Plaintiff/Petitioner Defendant/Respondent

REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested.

Name of Applicant:

Applicant is: Party Witness Juror Attorney Family Member or Guardian of a Victim

Victim Other

Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows:

1. Type of court proceeding: Criminal Civil Traffic Juvenile Other:

2. Hearing/Trial date: Time:

3. Nature of disability related impairment (specify):

4. Type of accommodation(s) requested. Be specific:

[Note - If requesting a sign language interpreter, specify type: American Sign Language interpreter (ASL), Certified Deaf Interpreter (CDI), or Communication Access Real Time Translation (CART). If requesting a spoken language interpreter, please use form CC-DC 41.]

5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify):

I request that this information be kept confidential to the extent allowed by law.

I certify that to the best of my knowledge this information is true and correct. I agree to provide medical documentation if required by the court.

Date Signature of Applicant/Applicant's Representative

Applicant/Applicant's Representative's Address Telephone No.

The clerk's office and the ADA Coordinator are available to provide further assistance.

The request for accommodation is GRANTED; or

Alternate accommodation(s) GRANTED (specify):

Date

The request for accommodation is DENIED.

Applicant does not qualify under the ADA.

It fundamentally alters the nature of the service program or activity as defined by the ADA.

It creates an undue burden on the court as defined by the ADA.

Judge/Administrative Official

If you disagree with this decision, you can file a Grievance. (Form CC-DC 50 is available for this purpose.)

CC-DC 49 (Rev. 12/2012)

Public User’s ADA Grievance Form

State of Maryland Judiciary

Americans with Disabilities Act Grievance Form

Name:

Address:

Telephone No. TTY/TTD

Case No.

Nature of disability:

Alternative contact person: Name

Address Telephone No. TTY/TTD

Which Court/Agency do you believe denied access? (Please attach a copy of any denial of request for accommodation.):

Court/Unit:

Location: Describe your grievance. Please specify dates, times, or incidents, and names or positions of Judiciary employees involved, if any, as well as names, addresses, and telephone numbers of any witnesses to any such incident. Attach additional pages if necessary.

What would you like to see happen?

I request that this information be kept confidential to the extent allowed by law.

This form should be submitted to the ADA Coordinator in the jurisdiction where the complaint originated. If you need assistance in completing this form, please contact the ADA Coordinator.

I certify that to the best of my knowledge this information is true and correct.

Type or Print Name Date Signature

You have the right to appeal the decision to the Office of Fair Practices. The appeal must be received or postmarked within 15 days after the complainant received the response.

Office of Fair Practices 2001 A Commerce Park Drive Annapolis, Maryland 21401

Fax: 410-260-3575

CC-DC 50 (Rev. 6/2013)

ConfidentialMedicalInformation

The ADA requires that medical information be collected and maintained on separate forms and in separate medical files.42 U.S.C. 12112(d)(3),(4)

Suggested Storage of Medical Information:• Keep documents in a separate medical file in a

different section of a file cabinet.• Keep medical information in a locked box; only

designated individuals have keys.