For Students: Reasonable Accommodation Request Form

Personal Information

First Name: * Last Name: *

MIT ID: *

Term Address:

Dorm Select One Baker House Bexley Hall Burton Conner East Campus MacGregor House Maseeh Hall McCormick Hall New House Next House Random Hall Senior House Simmons Hall FSILG Select One Alpha Chi Omega Alpha Delta Phi Alpha Epsilon Phi Alpha Epsilon Pi Alpha Phi Alpha Tau Omega Beta Theta Pi Chi Phi Delta Kappa Epsilon Delta Psi/No. 6 Delta Upsilon Delta Tau Delta Epsilon Theta Fenway House Kappa Alpha Theta Kappa Sigma Lambda Chi Alpha Nu Delta Phi Beta Epsilon Phi Delta Theta Phi Kappa Sigma Phi Kappa Theta Phi Sigma Kappa Pi Beta Phi Pi Lambda Phi Pika Sigma Chi Sigma Kappa Sigma Phi Epsilon Sigma Nu Student House Tau Epsilon Phi Theta Chi Theta Delta Chi Theta Xi WILG Zeta Psi Zeta Beta Tau

Phone:

Email: *

Academic Advisor:*

Department/Major: *

Select Student Type*: Select One Undergraduate Graduate Student Other

Term and Year of Entry:*

Year of Graduation:*

Accomodation Request 1

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.)

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 2

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 3

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 4

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 5

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Other Accommodations

Please list any other accommodations you may be requesting for extracurricular activities, events, or campus activities.

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.

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