Breadcrumb Menu Back Link Home Reasonable Accommodation Request Form Reasonable Accommodation Request Form Reasonable Accommodation Request Form First Name * Last Name * Email * MIT ID * Residence * Does Not ApplyBaker HouseBurton ConnorEast CampusMacGregor HouseMaseeh HallMcCormick HallNew HouseNew VassarNext HouseRandom HallSimmons Hall70 AmherstAshdown HouseEastgate ApartmentsEdgerton HouseGraduate Tower at Site 4Sidney PacificTang HallThe WarehouseWestgate ApartmentsAlpha Chi OmegaAlpha Delta PhiAlpha Epsilon PhiAlpha Epsilon PiAlpha PhiAlpha Tau OmegaBeta Theta PiChi PhiDelta Kappa EpsilonDelta Psi/No. 6Delta UpsilonDelta Tau DeltaEpsilon ThetaFenway HouseKappa Alpha ThetaKappa SigmaLambda Chi AlphaNu DeltaPhi Beta Upsilon Phone Academic Advisor * Department/Major * Select Your Student Type Undergraduate Graduate Student Other Term and Year of Entry * Year of Graduation * Accommodation Request 1 Course Name * Course Number * Days/Times Instructor * Instructor Email * Accommodation Request Please provide a detailed description of the accommodation(s) you are requesting (Note: Disability and Access Services must be given a reasonable amount of time to respond to an accommodation request.) Accommodation Request 2 Course Name Days/Times Course Number Instructor Instructor Email Accommodation Request Please provide a detailed description of the accommodation(s) you are requesting (Note: Disability and Access Services must be given a reasonable amount of time to respond to an accommodation request.) Accommodation Request 3 Course Name Course Number Days/Times Instructor Instructor Email Paragraph Please provide a detailed description of the accommodation(s) you are requesting (Note: Disability and Access Services must be given a reasonable amount of time to respond to an accommodation request.) Accommodation Request 4 Course Name Course Number Days/Times Instructor Instructor Email Accommodation Request Please provide a detailed description of the accommodation(s) you are requesting (Note: Disability and Access Services must be given a reasonable amount of time to respond to an accommodation request.) Course Number Accommodation Request 5 Course Name Days/Times Instructor Instructor Email Accommodation Request Please provide a detailed description of the accommodation(s) you are requesting (Note: Disability and Access Services must be given a reasonable amount of time to respond to an accommodation request.) Other Accommodations Request Please list any other accommodations you may be requesting for extracurricular activities, events, or campus activities. Captcha I am hereby requesting a reasonable accommodation for my disability. I grant permission to the Disability Coordinator and individuals identified by the Coordinator as necessary participants in the decision-making process (instructors, academic advisors, Medical Department staff, etc.) to review the pertinent information I have provided and discuss the matter with me and my health professional(s). If accommodations are not clearly identified in a diagnostic report, the Disability Coordinator can seek outside, professional clarification. 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. Submit If you are human, leave this field blank.