Public Accommodation Request Powered by Symplicity

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Student/Current & External Employee/Visitor Information

Please enter your information

Request Type*:

Medical Documentation is Required

You may upload documentation at the bottom of this form, or have you medical provider submit it directly to the office via email, fax, or mail. Contact information is found on the website. Your file will be reviewed when we have both this request form and documentation.

First Name*:

Last Name*:

Middle Name:

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

*Students: please use STUDENT ID - NOT Unique ID

*New External Applicants: Please enter phone number without dashes

*Visitors: Please enter phone number without dashes

Administrative Unit/College/DUHS:

Email*:

(Students and Employees please use your university issued email address)

Phone Number*:

Ex: xxx-xxx-xxxx

Do you have a scheduled interview?*:

In what department?*:

Please list the specific department

With whom are you interviewing?*:

Please give the interviewer's full name and telephone number

Supervisor's Name:

Supervisor's Telephone Number:

Human Resources Representative Name:

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, and then explain in detail how your medical condition impacts you currently as well as how it has impacted you in the past.

My diagnosed disability falls into the following category*:

Current Impact*:

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.

Historical Impact*:

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

Previous Accommodations:

Please list any accommodations you may have received in the past.

What accommodations are you requesting?*:

What accommodations are you requesting?

Accessibility Accommodation

Request Type*

Today's Date*

Accommodation Type*

UPLOAD DOCUMENTATION HERE:

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.

Today's Date*:

RELEASE/EXCHANGE OF INFORMATION

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 disability 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 disability and the documentation I have submitted with my parent(s), Duke University faculty and staff, and medical providers. All information obtained in diagnostic medical, psychological, and educational reports will be maintained and used in accordance with applicable confidentiality requirements.

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