Disability Accommodation Request Form

Please fill out this form if you have a documented disability that can affect your ability to learn in an online setting and would like to request accommodations to assist you in your online course(s).

Note: In order to process this form accurately, you will need to provide a doctor's note that outlines your request for your below accommodation.

Last Name:

First Name:

Student ID (if applicable):

Email:

Date:

Program:

Type of Disability:

Accommodation(s) requested: e.g. Additional time on assignments, etc. Please note if requesting extended time, explain the reasons and length of time

Semester(s)/Courses(s):

Indicate the semester(s) and courses (s), in which you intend to enroll. Please note that if this is a long-term disability you will not need to resubmit this form every semester. This information will remain on your student record.

Supporting Documentation:

Decision:

Date Processed:

Contact Information