State of California
Reasonable Modification or Accomodation Requet

NOTE: This form is to be used only by inmates/parolees with disabilities

Inmate/Parolee's name: Rodgers
CDC Number: V02538
Assignment: Slave School?
Hours/Watch: PM

In accordance with the provision of the Americans with Disabilities Act (ADA), no qualified individuals with a disability shall, on the basis of disability, be excluded from participation in, or be denied the benefits of the services, activities or programs of a public entry, or be subjected to discrimination.

You may use this form to request a specific reasonable modification or accommodation which, if granted, would enable you to participate in a service, activity or program offered by the Department/institution/facility, for which you are otherwise qualified/eligible to participate.

Submit this completed form to the institution or facility's Appeals Coordinator's Office. A decision will be rendered within 15 working days of receipt at the Appeals Coordinator's Office and the completed form will be returned to you. If you do not agree with the decision on this form, you may pursue further review. The decision rendered this form constitutes a decision at the FIRST LEVEL of review.

To proceed to SECOND LEVEL, attach this form to an Inmate/Parolee Appeal Form (CDC 602) and complete section "F" of the appeal form.

Submit the appeal with attachment to the Appeals Coordinator's Office within 15 days of your receipt of the decision rendered on this form.

If you are not satisfied with the SECOND LEVEL review decision, you may request THIRD LEVEL review as instructed on the CDC 602.

Modification or accommodation requested
Description of disability: Aged, ailing, triple CCCMS, mentally ill - forced to exist in a fishbowl dorm with demon. Will volunteer to be executes, one bullet between my eyes.
What verification do you have of your disability? Medical files

Describe the problem: I am being forced to live in a fishbowl/dorm where demons are always watching forced to attent the white man's 'Uncle Tom' Slave School, experiencing end of life twilight years with thoughts of being buried deep in a cold dark grave alone and maggots are running in and out of every orifice of my body. Loud voices are screaming "you're dead, dead," "the dirty, lying, racist, whiteman killed you." I am severely depressed, negative, hate-filled for the dog-ass racist whites, no friends. I can't get along with anyone. People just don't seem to understand my valid, legitimate, obsessive, verbal diatribe of trivial for those cowardly lying KuKluxKlan white killers who murdered me (RIP in martyrdom elder Otis Lee Rodgers). Relief sought. That I be transferred back to A level 3 yard, single-cell. That's the reason I stop taking my meds in protest.