Disability Disclosure And Accommodation Form printable pdf download

Disability Disclosure And Accommodation Form

Disability Disclosure and Accommodation Form

This form documents your self-disclosure of your disability and your request(s)

for accommodations. This information is kept confidential at the highest level

possible.

Name: __________________________________________________________

Campus Address:

__________________________ Extension: ____________

Disability disclosed: ________________________________________________

Accommodation(s) requested: ________________________________________

Signature: ________________________________

Date: ________________

For Office Use Only

Is the request reasonable? Yes ______ No ______ Date: _______________

Explain: _________________________________________________________

Is there a preferred alternative reasonable accommodation? Yes ____ No _____

Explain: _________________________________________________________

Action: __________________________________________________________

Disability Service Provider’s Signature: _________________________________

Date: ________________

Disability Disclosure And Accommodation Form