ADA Accommodation Request Form

Person needing accommodation:

Person making request IF different than the person needing accommodation:

Case Information:

Accommodation(s) Requested:

In some instances, documentation from a qualified health care provider may be required.  These requests will be limited to documentation that (a) establishes the existence of a disability, (b) identifies the individual’s functional limitations, and (c) describes how the requested accommodation addresses those limitations.  Any cost for obtaining documentation shall be the responsibility of the person requesting the accommodation.