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
Please identify your disablity:
How has your disability previously impacted your ability to succeed in school or work?
What academic adjustments, accommodations, or support services have you found helpful in your previous experiences (please describe in detail)?
What have you used in the past?
What additional adjustments or accommodations for learning, tests, assignments, etc. would you require while a student at Washington University of Science and Technology (WUST), if any?
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:
Please attach all documentation you are submitting with this form as verification of disability.
Only complete forms submitted with documentation will be reviewed.

Attach Files
Draw your signature into the box below. Your signature attests to the veracity of your submitted request and legitimacy of all submitted documentation.

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Request for Disability Accommodation Form

Request for Disability Accommodation Form

Disability Disclosure