Request for Reasonable Accommodations

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Students with a documented disability under the Americans with Disabilities Act have the option of making their disability known to University Officials. It is a personal decision whether to self-identify a disability and ask for an accommodation. A decision not to self-identify will be understood and respected and any discussion to consider this decision will be treated with appropriate confidentiality. However, disclosure is necessary inorder for the student to receive requested reasonable accommodations. All requests, as well as documentation, will be considered confidential.

Requests for accommodations should be made at least 30 days from the start of the semester.

First Name

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Last Name

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Please provide 8 digit URID#

Date of Birth

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M-D-Y

Street Address

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City

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State

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Zip Code

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Email Address

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Phone Number

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Student Status

Student Program

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Department

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Please provide a description of your disability.

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Please list the accommodations you are requesting.

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Did you utilize disability services at your previous college or university?

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Yes

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After submitting this form, please provide written documentation to the Access Services Coordinator. Services cannot be provided for a student who does not submit documentation of the disability and need for the accommodations requested.

Documentation must be written by a licensed or credentialed examiner; which includes:
- a diagnostic statement identifying the disability
- a description of the diagnostic methodology
- a description of the current functional limitations
- a description of the expected duration and progression of the condition
- and a rationale and justification for all requested accommodations

Please note that submission of only an IEP or 504 Plan may not be sufficient.

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I have read and understand the statement regarding providing documentation necessary for supporting my request for reasonable accommodations.

I do not understand the statement regarding providing the required documentation necessary for supporting my request for reasonable accommodations.

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By entering your name in the textbox, you will be in agreement of the following statement: I authorize the Graduate Education and Postdoctoral Affairs Office to inform my course directors and/or Graduate Program Director of the required accommodations. I understand that all correspondence regarding my disability is considered confidential and is protected by the regulations stated in the Family Educational Rights and Privacy Act.

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