Request for Disability Accommodation Form

This is a confidential self-disclosure form for students/employees requesting accommodations.

If you wish to disclose a disability, please complete this form and include all relevant supporting documentation. If you have questions, please call 703-941-2020 and request to connect with the ADA Coordinator for documentation guidelines or other information.

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
WUST Email
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Are you requesting accommodations as a student or employee?

Are you requesting accommodations as a student or employee? Student Employee
Disability Disclosure

Please indicate the nature of your disability and indicate the diagnosis where appropriate.

Note: You are not required to disclose the specific nature of your disability, but you will need to provide enough information to assist us in determining appropriate accommodation.
Please indicate the type of disability (check all that apply):

Please indicate the type of disability (check all that apply): Learning Disability Physical Disability Sensory Disability (e.g., visual, hearing) Mental Health Condition Chronic Health Condition Other Other
Briefly describe the nature of your disability (optional):
How has your disability previously impacted your ability to succeed in school or work?
Requested Accommodation

As a private university WUST can provide only “reasonable accommodations” listed below. Please indicate the types of accommodation you believe would be helpful for you. These may include, but are not limited to, the options listed below. The Center for Student Success will work with you to determine what accommodations are appropriate.
Please select the accommodations you may require:

Please select the accommodations you may require: Extended time for exams Quiet testing or exam area Note-taker assistance or lecture slides Accessible classroom locations Alternative formats for course materials (e.g., large print, audio) Preferential seating Service Animals (Emotional support dogs are not allowed) Other Other
If you have previously received accommodations at another institution, please describe them here (optional):
What additional accommodations for work might you require while an employee at Washington University of Science and Technology (WUST), if any?
Do you have a mobility concern that would prevent you from evacuating a building in an emergency?
Have you ever had an illness as a result of your disclosed disability that has caused you to be absent from school or work for a long period of time? If yes, please describe:
Documentation of Disability

To establish eligibility for accommodations, we may require documentation from a licensed healthcare professional or qualified evaluator (e.g., doctor, psychologist, etc.). Documentation should describe your disability and how it impacts your performance.

Submissions without documentation may require additional verification before the accomodation can be approved.
Do you have documentation of your disability?

Do you have documentation of your disability? Yes No
Please attach all documentation you are submitting with this form as verification of disability.
Acknowledgement and Signature

By signing below, I acknowledge that:
• The information provided on this form is accurate to the best of my knowledge.
• I am aware that providing false information may affect my eligibility for accommodations.
• I understand that all information regarding my disability and accommodations will be kept confidential according to FERPA and ADA guidelines.
• I consent to the release of necessary information to faculty or staff involved in implementing accommodations.
Draw your signature into the box below. Your signature attests to the veracity of your submitted request and legitimacy of all submitted documentation.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Request for Disability Accommodation Form

Request for Disability Accommodation Form

Disability Disclosure

Requested Accommodation

Documentation of Disability

Acknowledgement and Signature