Public Accommodation Request Powered by Symplicity

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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 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:

Accessibility Specific Information

Instructions: There is much variability within each accessibility category, and therefore, the type of accommodations needed can vary significantly. Below, you will find descriptions of the various types of disabilities recognized in the United States. Student/Employee/Visitor needs vary according to each individual. Therefore, it is important for the participating student/employee/visitor to clarify the particular accommodations she or he requests.

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:

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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