Public Accommodation Request

* indicates a required field

Student/Current & External Employee/Visitor Information

Please enter your information

Request Type *

First Name *

Last Name *

Middle Name

Student/Current Employee/New External Applicant/Visitor ID *

*Students: please enter UNIQUE ID - NOT Student ID

*Current Employees: enter Unique ID

*New External Applicants: Please enter phone number without dashes

*Visitors: Please enter phone number without dashes

Personal Phone Number *

Ex: xxx-xxx-xxxx

Email *

Students:please use your university issued email address

Employees: please use your preferred email address

Accommodation Request Information

Instructions: Below, you will find descriptions of the various types of disabilities recognized in the United States. Please select the category of your disability that best represents the nature of your medical condition.

My diagnosed disability falls into the following category *

What accommodations are you requesting? *

Accessibility Accommodation

Request Type *

Today's Date *

Please list the accommodation(s) that you are requesting *

Today's Date *

RELEASE/EXCHANGE OF INFORMATION

Fire/Safety Evacuation

We ask that all employees and students identify any medical limitations that may limit their ability to effectively and safely evacuate during an emergency situation. We collect this information to assist our office in developing an emergency evacuation plan in conjunction with the University. Self-identification is voluntary, and the information you provide will be kept confidential and only shared with those individuals who have responsibilities in facilitating the emergency evacuation plan. If additional information is needed, we will contact you as soon as possible. The Disability Management System representative will forward the completed form to the Occupational and Environmental Safety Office (OESO) Fire Safety Division, 1411 Hull St. Box 90427, Fax 919-684-5487.

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