Graduate Student Accommodation Request Form

Background Information

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Your full name:

School/Degree Program:

Anticipated graduation year:

Your email address:

Email address must be of a valid format.

Accommodation Request Information

What is your disability or disabilities?(Required) This field is required.

Is this condition or disability considered temporary?(Required)

Yes No

This field is required.

What disability related barriers or challenges do you experience at Dartmouth? Consider sharing impacts related to all aspects of your roles at Dartmouth including academic barriers, housing, dining, and/or others (e.g., athletics).(Required) This field is required.

If you are also an employee, then please describe any disability related barriers or challenges experienced in your role as an employee (e.g., research lab, teaching roles, etc.). You should also include information about your employee title, department, and supervisor. This field is required.

What accommodations are you requesting?(Required) This field is required.

If you have previously used academic or workplace accommodations, please describe them here including the setting and when they were last used.(Required) This field is required.

Are you returning from medical leave?(Required)

Yes No

This field is required.

What is the anticipated date of your return? This field is required.

Any additional information you would like to share? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Background Information

Accommodation Request Information

Supporting Documentation

Submission