Web Site Accessibility Certification Review Request Form
State of Connecticut
Web Site Accessibility Committee
WEB SITE CERTIFICATION REVIEW REQUEST
INSTRUCTIONS
1. Prior to submitting this form, you should evaluate your web site and correct all problems in
accordance with the Six Steps to Accessibility Certification document available at
2. For resources, tools and tutorials that will assist you in making your web site accessible, visit the Web site Accessibility Committee web site at
3. After entering all of the information below, please submit this form by mail or FAX to:
Pam Casiano, Web Site Accessibility Committee Chair
c/o Department of Education
165 Capitol Avenue, Room 320
Hartford, CT 06106
FAX: (860) 713-7038
4. If you have any questions regarding your web site accessibility obligation, the review process or this form, please contact Pam Casiano by phone at (860) 713-6604, or through email:
pam.casiano@
Agency/Branch/Organization: ____________________________________________________
Address: _________________________________________________________
_________________________________________________________
_________________________________________________________
Webmaster: ___________________________________________________________________
Telephone: _____________________________FAX: __________________________________
Email: _____________________________________________________________
Web site URL(s) please list subwebs separately: ______________________________________
________________________________________________________________________________ ________________________________________________________________________________
Having reviewed my Web site as listed above and corrected all accessibility issues in accordance with the requirements of the Web site Accessibility Committee and the documentation provided on its web site, I hereby request that a Committee member review my web site for the purpose of accessibility certification.
Webmaster Signature _______________________________________ Date ____________
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