Accommodations Form Accessible Text (Bottom of the Form)

I hereby agree that the Equal Opportunity and Compliance Office has my permission to contact the below listed physician or other health care provider(s) to obtain information related to: my disability; any related limitations; and recommendations on necessary accommodations. 

(NOTE: If you have questions about this release, you may complete a paper version of this form after speaking with an EOC Office member about those questions.)

I understand that I must also submit the “Documentation of Disability” form signed by an authorized physician or other health care provider.  This form should include a description of my disability; any related limitations; and recommendations for accommodation(s) and/or service(s).  

By typing my name below, I affirm that electronic submission of this request indicates my consent to the University’s verification of any information contained. I also affirm that I understand that relevant information about my limitations and restrictions obtained in this process may be shared with the supervisor(s) in my immediate work unit and other University offices that may be involved in assisting in the development of reasonable accommodations to assist me in completing my assigned work related responsibilities.