Reasonable Modifications and Communication Assistance Request Form
Nondiscrimination and Disability
*If you need help reading this information or communicating with us, ask us or call 1-877-423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).
(for DFCS programs, services and activities)
In accordance with federal civil rights laws and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Programs that receive federal financial assistance from the U.S. Department of Health and Human Services (HHS), such as Temporary Assistance for Needy Families (TANF), and programs HHS directly operates are also prohibited from discrimination under federal civil rights laws and HHS regulations.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or who have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
CIVIL RIGHTS COMPLAINTS INVOLVING USDA PROGRAMS
USDA provides federal financial assistance for many food security and hunger reduction programs such as the Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR) and others. To file a program complaint of discrimination, complete the Program Discrimination Complaint Form, (AD-3027) found online at:
https://www.usda.gov/sites/default/files/documents/USDA-OASCR P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
- mail: Food and Nutrition Service, USDA
1320 Braddock Place, Room 334, Alexandria, VA 22314; or
- fax: (833) 256-1665 or (202) 690-7442; or
- phone: (833) 620-1071; or
- email: [email protected].
For any other information regarding SNAP issues, persons should either contact the USDA SNAP hotline number at (800) 221-5689, which is also in Spanish, or call the state information/hotline numbers (click the link for a listing of hotline numbers by state); found online at: SNAP hotline.
CIVIL RIGHTS COMPLAINTS INVOLVING HHS PROGRAMS
HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head Start, the Low Income Home Energy Assistance Program (LIHEAP), and others. If you believe that you have been discriminated against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual orientation, and gender identity), or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance, you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone else.
To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance through HHS, complete the form online through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or email: [email protected]. For faster processing, we encourage you to use the OCR online portal to file complaints rather than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at [email protected] or call OCR toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for filing a complaint.
This institution is an equal opportunity provider.
You may also file other discrimination complaints by contacting your local DFCS office, or the DFCS Civil Rights, ADA/Section 504 Coordinator at 2 Peachtree Street N.W., Fl. 29, Atlanta, GA, 30303, 404-657-3735. For complaints alleging discrimination based on limited English proficiency, contact the DHS Limited English Proficiency and Sensory Impairment Program at: Two Peachtree Street, N.W., Fl. 29, Atlanta, GA 30303 or call 404-657-5244 (voice).
To download the Notice of ADA/Section 504 Rights and the joint Nondiscrimination Statement, use the following links below:
Notice of ADA/Section 504 Rights and Joint Nondiscrimination Statement - English standard print format
Notice of ADA/Section 504 Rights and Joint Nondiscrimination Statement - English large print format
Aviso de derechos según la Ley de Estadounidenses con Discapacidades (ADA)/sección 504 y Declaración conjunta de no discriminación Letra en tamaño normal Español
Aviso de derechos según la Ley de Estadounidenses con Discapacidades (ADA)/sección 504 y Declaración conjunta de no discriminación Español- Letra grande
Customers with Disabilities: Requesting a Reasonable Modification and Communication Assistance
Qualified individuals with a disability have a right to request and DFCS must provide Reasonable Modifications when the modifications are necessary to avoid discrimination based on disability. For example, we may change policies, practices, or procedures to provide equal access. Examples of Reasonable Modifications may include but are not limited to face-to-face interviews and telephonic signatures (if applicable). To ensure equally effective communication, we provide persons with disabilities or their companions with disabilities communication assistance, such as sign language interpreters. Our help is free. DFCS is not required to make any modification that would result in a fundamental alteration in the nature of a service, program or activity or in undue financial and administrative burdens.
Learn more about how to request a Reasonable Modification and Communication Assistance.
Reasonable Modifications and Communication Assistance Request Form
To print a Reasonable Modification or Communication Assistance form, click an option below:
Reasonable Modification or Communication Assistance English standard print format
Reasonable Modification or Communication Assistance English large print format
Formulario de solicitud de modificaciones razonables y asistencia de comunicación Letra en tamaño normal Español
Formulario de solicitud de modificaciones razonables y asistencia de comunicación Español- Letra Grande
Requests for Reasonable Modification and Communication Assistance can be emailed to [email protected].
All eligibility workers have the responsibility and authority to offer, grant, and implement necessary reasonable modifications to customers with disabilities if they can be readily provided. Common examples of reasonable modifications and communication assistance but not all, include: help filling out and explaining applications and re-certification forms for benefits, help gathering documents required by the program to support initial and ongoing eligibility for benefits, and providing notices, applications, re-certifications, and other program materials in alternate formats (e.g., Braille, data format, audio CD, large print, etc.), to customers with visual or hearing impairments.
Considerations of and decisions concerning a customer’s request for reasonable modification may incorporate the following factors, assessed cooperatively with the customer: How the disability limits the customer’s ability to comply with program eligibility procedures, reasonable modification options that address those limitations; and the effectiveness and feasibility of the proposed options. Provisions of reasonable modifications are based on a fact-specific inquiry that is to be assessed on a case-by-case basis. Once your Request for Reasonable Modification and Communication Assistance is received, it is reviewed by a staff member. If a staff member has questions or if the requested Reasonable Modification or Communication Assistance needs further explanation or clarification, the staff member will contact you using the information you provided.
If you need help communicating with us in a language other than English, ask us or call 1-877-423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).
For a complete list of DFCS ADA/Section 504 District and Regional Coordinators, including the Statewide Senior SNAP and RSM Coordinators, and the DFCS ADA/Section 504 Statewide Coordinator, click here .
For large print versions of DFCS applications, renewals, and other program materials visit https://dfcs.georgia.gov/food-stamps.
To request an alternate format other than large print, contact your caseworker or complete a Reasonable Modification and Communication Assistance Request Form.
ADA-related posters in English and en Español
Notice of Free Interpretation Services and Accessibility Assistance Poster
ADA-related policies and procedures (Search the "Division of Family and Children Services" manuals and policies)
DFCS Discrimination Complaint Procedures and Complaint Form
Civil Rights Complaint Process
Proceso de Queja por derechos civiles y ADA/ Sección 504 ante la DFCS
Formulario de queja de Derechos Civiles del DFCS, ADA/Sección 504
- What kinds of Reasonable Modifications may be provided for help accessing programs and services? Preference will be given to your request that you identify to help you access the services. For example, if you have an intellectual disability and you need help understanding forms that need to be completed to determine eligibility for benefits, our staff can provide help. If you have a disability that limits your ability to complete the forms that determine eligibility, we can assist with that. If you have ADHD and need a reminder of an upcoming appointment, we can provide that. If you need communication assistance and request application forms and other vital documents in alternative formats, such as Braille, we can provide that. If you are Deaf and need a sign language interpreter, we will provide one. Reasonable Modifications are not the same as the programs for which you might apply. For example, asking for Medicaid itself is not considered a Reasonable Modification, but any aid or service that would allow you to participate in the Medicaid eligibility process may be considered a Reasonable Modification.
- Is my local DFCS office accessible for my wheelchair? Yes. To schedule an appointment, please contact your DFCS district or regional ADA/Section 504 Coordinator. Is there a hardship waiver where I can skip parts of the program eligibility process due to my disability? All applicants must satisfy the individual program requirements in order to be determined eligible. DFCS cannot approve policy requirements set forth by outside agencies who determine policy requirements. This would mean if a Reasonable Modification is requested for a policy requirement for Medicaid, an applicant would be directed to request the modification from the Georgia Department of Community Health, the organization that administers the Medicaid program. If a request for a waiver of policy requirement for Food Stamps is received, the applicant would be referred to the United States Department of Agriculture, Food and Nutrition Services, the organization that determines eligibility requirements. If you need assistance in meeting a policy requirement, such as obtaining verification, please speak to your case worker about any modifications that can be made.
Questions specific to Food Stamps (SNAP):
- Can I deduct shelter expenses from my income to qualify for Food Stamps? Households are allowed a shelter deduction for shelter expenses they are billed for. Monthly shelter expenses that are more than 50% of the household’s income after all other SNAP deductions are allowed may be deducted. The excess shelter amount is $569 per month for SNAP households unless there is a household member in the SNAP case who is elderly (60 years old and older) or disabled (receiving Social Security Disability, SSI or other Disability Income as defined by SNAP). Elderly or disabled households are able to deduct the full excess shelter amount as a deduction.
- Can I deduct medical expenses from my income to qualify for Food Stamps (SNAP)? Individuals who are elderly (60 years and older) or disabled (receiving Social Security Disability, SSI or other Disability Income as defined by SNAP) are allowed a medical deduction for medical expenses they are billed for. Medical expenses that are more than $35 per month may be deducted from the household’s income. Elderly or disabled individuals who have more than $35 per month in out of pocket medical expenses may be eligible to receive the standard medical deduction. The standard medical deduction amount is $136. The amount allowed as a medical deduction is $101 ($136-$35 exclusion). Elderly or disabled individuals who have more than $136 per month in out of pocket expenses may be eligible to claim a higher medical deduction amount. These households must provide proof of their medical expenses to receive the deduction.
Questions specific to Medical Assistance:
- Can I deduct shelter expenses from my income to qualify for Medicaid? There are several medical assistance programs in Georgia. Available deductions depend upon the type of medical assistance program for which you apply.
- Can I deduct medical expenses to qualify for Medicaid? There are several medical assistance programs in Georgia. Available deductions depend upon the type of medical assistance program for which you apply.
- What Medicaid services or benefits would my disability exclude me from receiving or participating in? None. Your disability will not exclude you from receiving or participating in a Medicaid class of assistance.
- Are reasonable modifications for my disability extended from third party entities of the state as it relates to Medicaid? Yes. Any third-party entities involved in an interaction with the customer have guidelines set to address Reasonable Modifications. A common entity that may require contact with the customer is the care management organization (CMO) that partners with Medicaid and coordinates care services for certain Medical Assistance programs. These CMOs include WellCare, Amerigroup, CareSource, and Peach State Health. Modifications for customers, upon request to the CMO, may include TTY/TDY services for phone calls, language assistance, large print, Braille, audio assistance---please call your CMO Member Services phone number to inquire.
Questions specific to Temporary Assistance to Needy Families (TANF):
- If I have a physical or mental disability, can I apply for TANF assistance? An individual with a disability has a legal right to equal access to all TANF benefits and services for which they are eligible. All individuals must have an opportunity to participate in and benefit from DFCS programs and services equal to those provided to an individual with no disabilities.
- I have a disability and I am unable to work. What verification do I need to be eligible for TANF?
Once a customer is interviewed and discloses a disability, an assessment will be completed to evaluate the customer’s strengths, barriers to employment, and reasonable accommodations that will be needed to meet the goal of self-sufficiency. A customer with a disability/limitation is not exempt from work requirements or personal responsibilities. Work requirements are mandated based on the belief that an individual will be better off when provided with employment and training opportunities rather than continuing to receive public assistance.
- What type of work programs will be provided for customers with disabilities? DFCS collaborates with employers, educators, trainers, and support service providers to ensure that TANF recipients have access to the resources needed to achieve the goal of self-sufficiency. ADA requirements apply to government agencies and to private entities that have entered contracts with DFCS to provide training and services. Therefore, entities contracted with DFCS are obligated to provide equal access to their services and programs for TANF customers with disabilities. These entities must provide Reasonable Modifications so that TANF customers with disabilities are able to receive the services and benefits for which they are otherwise eligible.