*Students: please use STUDENT ID - NOT Unique ID

*Current Employees: Use Unique ID

*New External Applicants: Please enter phone number without dashes

*Visitors: Please enter phone number without dashes

Ex: xxx-xxx-xxxx

Please submit your direct line number and extension if applicable.

Ex. xxx-xxx-xxxx Ext. xxxx

Students:please use your university issued email address

Employees: please use your preferred email address

Ex. 1234 May St. Durham, NC 27707

Ex. 402 Oregon St., Suite 102, Durham, NC 27708

Please list the specific department

Please give the interviewer's full name and telephone number

Ex. xxx-xxxx

In as much detail as possible, please describe how your disability currently impacts and substantially limits your ability in the academic/employment or campus setting.

In as much detail as possible, please describe how your disability has affected your life in the past.

If you have medical documentation that supports your request, please upload it here. If you do not, go ahead and submit your request, and then have your medical provider send it to the office via email, fax, or mail. Our website has the office contact information. Documentation MUST be submitted to proceed in our process.

By typing my name below, I give Duke University, including but not limited to DMS, EOHW, HR, E&O, FMD, Fire and Safety, and my work unit permission to explore possible coverage and reasonable accommodations under the Americans with Disabilities Act and the ADA Amendments Act. I understand that all information obtained during this process will be maintained and used in accordance with applicable confidentiality requirements.

I understand that it is my responsibility to provide pertinent documentation from my healthcare provider(s) regarding my medical condition(s) that must include: 1) documentation that demonstrates that your medical condition is substantially limiting of a major life activity (such as doctor visit notes); 2) a link between the requested accommodation and the health condition; 3) the anticipated duration/length of time of the health condition; 4) whether the requested accommodation is medically necessary or for comfort.

Please type your name in acknowledgement and agreement to the Exchange of Information statement below:

In order to explore possible coverage and reasonable accommodations, it is often necessary for the staff of Disability Management System (DMS) / Student Disability Access Office (SDAO) to discuss documentation and the individual's medical condition with the student's parent(s), Duke University faculty and staff, as well as medical providers such as licensed physicians, psychologists, or other qualified professionals. By typing in my name and clicking on the "SUBMIT" button, I hereby give my permission for members of DMS/SDAO staff at Duke University to exchange information regarding my medical condition and the documentation I have submitted with my parent(s), Duke University faculty and staff, and medical providers or mental health providers. All information obtained in diagnostic medical, psychological, and educational reports will be maintained and used in accordance with applicable confidentiality requirements.