Accommodation Request Form

Request Form Information

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Nature of this report(Required):

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Please identify the type of accommodation you are requesting.

Date of Request(Required):

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Please select today's date

Personal Information

REQUIRED: Please list your information below. (If you are a supervisor requesting accommodations on behalf of your employee, please list the name of the employee for which the accommodation is being requested.) Please note, student employees should be listed as employees on this form.

Full Name

Select Gender

Beach ID Number

Preferred Phone number

Campus Email address

Office or Classroom Location

Additional Information

What is your specific functional limitation (physical or mental impairment that impacts one or more major life activities) or religious need for which you are requesting accommodation?(Required) This field is required.

What specific accommodation are you requesting? i.e. accessible office equipment or software, schedule adjustments, exam changes (for student religious/pregnancy accommodations only, please list the date of the exam, class number, professor, and the changes you would like.) *Please note, while preferences for accommodations will be taken into account, our office reviews the restrictions and determines a reasonable accommodation that may or may not be your top preference.(Required) This field is required.

What date are you requesting the accommodation to begin? (If the date of the accommodation is sooner than 5 business days from the date of the request, please contact the office directly by calling 562-985-8256)(Required) This field is required.

What is the duration of the requested accommodation? (i.e. two weeks, five days, a month, permanent, etc.)(Required) This field is required.

Supporting Documentation

If you have any supporting documents or note from a medical provider or religious leader, you may attach that to this form. If you do not provide documentation in this form, or if there is additional information needed for the Interactive Process, you may be asked to provide documentation. Please note, we only need the functional limitation(s) and duration of the requested accommodation. Do not provide a diagnosis or medical history.

5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Request Form Information

Personal Information

Additional Information

Supporting Documentation

Submission