Employee Request for Accommodations

Personal Information

First Name *

Last Name *

Disability

Date of Birth *

Year

Month

Day

Campus Email

Disability services will use your campus email address as the primary method of communicating with you regarding appointments and your accommodations. Please check your email account regularly.

Employee Number * 12345678

Address

Street *

Apartment

City *

State *

Zip *

Local Phone

Cell Phone

Work Information

Work Location *

Work Phone *

Supervisor *

Supervisor's Department

Supervisor's Address

Supervisor's Phone

Union Affiliation

Reason(s) for registering with Disability Services *

Current state Vocational Rehabilitation clients

Mass Rehab Commission, Mass Commission for the Blind, etc.

Counselor's Name

Counselor's Address

Counselor's Phone

Counselor's Email

Privacy Agreement

By checking the box below, I authorize Disability Services to recommend appropriate support services based on my documented disability and as agreed upon by Disability Services, my supervisors, and myself.

I agree *

I agree

Date

Year

Month

Day

Leave this field blank

Disability Services

Employee Request for Accommodations

Contact Information

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