ADA Reasonable Accommodation Request Form

Fields marked with * are required.

Your Name: *
Enter your name. Required.       
Title/Position:*
Enter your title and/or position at UMass Dartmouth. Required       
Department: *
Enter the department you work in. Required.       
Work Phone Number: *
Enter your phone number at work. Required.       
Home or Cell Phone Number: *
Enter your phone number at work. Required.       
Details on your disability: *
Please specify the disability you have for which you are requesting accommodation. Required.       
Accommodation requested: *
What reasonable accommodation are you requesting at this time? Required.        
Length of time: *
How long do you believe you will need this accommodation? Required.       

Please submit separately a physician's (or other appropriate health care provider) letter verifying your disability, explaining in detail the recommended accommodation and how the recommended accommodation is necessary based on your disability. This documentation should be typed or printed on letterhead, dated, signed and legible with the name, title and professional credentials of the evaluator or medical provider.

The ADA Coordinator will review your request, and you will be contacted to discuss your requested accommodation.

The above information is complete and accurate to the best of my knowledge and belief. This information will be maintained confidentially to the extent practicable under the circumstances.

Your email address: *
Enter your email address. Required.