Student's Reasonable Accommodation Request Form

Fri, 10/03/2008 - 12:19 — administrator

Name: *

MIT ID: *

Address:

Phone:

Email: *

Academic Advisor: *

Department/Major: *

Year of Graduation: *

Please provide a detailed description of the accommodation(s) you are requesting (Note: Disabilities Services must be given a reasonable amount of time to respond to an accommodation request.)

Request 1

Course Name:

Accommodation Request:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Request 2

Course Name:

Accommodation Request:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Request 3

Course Name:

Accommodation Request:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Request 4

Course Name:

Accommodation Request:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Request 5

Course Name:

Accommodation Request:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Other Accommodations:

Please list any other accommodations you may be requesting for extracurricular activities, events, or campus activities. (When requesting testing/exam accommodations, please use the Exam Accommodations Request Form).

I am hereby requesting a reasonable accommodation for my disability. I grant permission to the DSO staff as necessary participants in the decision-making process (i.e., instructors, academic advisors, Medical Department staff, etc.) to review the pertinent information I have provided and to discuss the matter with me and my health professional(s). In general, Institute policy calls for reasonable accommodations to be made for students with disabilities on an individualized and flexible basis. It is the responsibility of students with disabilities, however, to seek available assistance at MIT and to make their needs known.