Accessibility Accommodations Request

First Name

Last Name

Student ID

Email

Phone number

Type of Accommodation Requested

Extended time on exams or assignments Note-taking assistance or access to lecture recordings Assistive technology (e.g., screen reader, speech-to-text) Alternative textbook formats (digital, large print, audio) Priority seating or lab adjustments Physical accessibility (e.g., elevators, restrooms, simulation access)

Other

Please describe

Please describe your request in detail

Include any challenges experienced, your needs, and how the accommodations will support your success.

Semester accommodations are requested

Fall Spring

Year

Have you previously submitted documentation to the Dean of Students?

Yes No

Upload any supporting documentation

Please select a file

Review Consent

I understand that this form will be reviewed confidentially by the Dean of Students, and I may be contacted for additional information.

Documentation Consent

I understand that documentation may be required to determine reasonable accommodations.

Acknowledgement Consent

I understand that my accommodation plan will be shared only with faculty/staff who have a legitimate educational need to know, in compliance with FERPA and ADA.

Digital Signature

Type Full Name

Today's Date

Accessibility Accommodations Request Form