Name:    
Address:
Phone:    Fax:    Email: 

I certify that a handicap accessibility self-evaluation has been:

completed on date or 
partially completed on date.

The results of the self-evaluation (s) is (are) as follows:

The recipient's program, when viewed in its entirety, is accessible and no corrective actions are required.

The recipient's program, when viewed in its entirety, is accessible, but some corrective actions will be made.

The recipient's program, when viewed in its entirety, is not accessible.  FOR SPONSOR ONLY:  Corrective action will be made by: date.

I understand that, if the organization has 15 or more employees, information on how the self-evaluation was conducted is to be made available for public inspection for 3 years after its completion.  I also understand that this information will be available to ACTION officials upon request.

Each OAVP station and VISTA site must submit this certification form to its OAVP Sponsor or VISTA project.  Each OAVP sponsor and VISTA project must submit one form to its ACTION State Office.

Station Representative  response: