Employee Accommodation Request Form

Background Information

Enable additional features by logging in.

Your full name:

Your Dartmouth ID:

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Questions

Employee's Title(Required) This field is required.

Employee's Department(Required) This field is required.

Employee's Supervisor(Required) This field is required.

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 in your role as an employee at Dartmouth?(Required) 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. This field is required.

Are you returning from medical leave?(Required)

Yes No

This field is required.

If so, 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

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

Email me a copy of this report

Background Information

Questions

Supporting Documentation

Submission