Disability Services Accommodation Request

Disability Services Accommodation Request — Form Fields

This applications template includes 11 fields. Apply for academic or workplace accommodations due to a disability or medical condition. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Student ID or Employee ID (text, required)
• Setting (dropdown selection, required) — options: University/College, Workplace, K-12 School, Testing Center, Other
• Type of Accommodation Requested (checkboxes, required) — options: Extended Time, Quiet Testing Room, Note-Taker, Sign Language Interpreter, Assistive Technology, Flexible Scheduling, Other
• Description of Your Disability or Condition (long text, required)
• Supporting Documentation from Healthcare Provider (file upload, required)
• How Do the Accommodations Help You? (long text, required)
• Have you received accommodations before? (multiple choice, required) — options: Yes, No
• Previous Accommodations (if applicable) (text, optional)