Medical Accommodations Request Form

Offices and Administration

Medical Accommodations Request Form

Please complete the Medical Accommodations Request Form in full and review the corresponding website for important information.

- indicates required field

First Name

Middle Name

Last Name

UNA ID Number

UNA Email Address

Cell Phone Number

Semester Requesting Accommodations to Begin

Academic Classification

I Am Requesting:

If other, please specify

Relevant Diagnosis (Disability or Chronic Medical Condition)

How do you anticipate managing your symptoms in other campus settings (e.g. classroom, dining halls, libraries, etc.)

Explain how the accommodations you are requesting will impact your current symptoms.

Please list the health care professional(s) you are authorizing to provide us with information about you. This will be used for consideration by the Special Accommodations Review Committee.

Full Name of Provider

Phone Number

Provider Address

Provider Phone Number

By my signature below, I give my consent for the Medical Accommodations Review Committee to contact my treating professional for additional information as needed. Any such discussion will focus on the disability described on this form only.

Student Name

Date

This consent will expire on:

Please make sure all required fields have been filled out correctly.

Your Medical Accommodations Request Form has been submitted. Please allow 7-10 business day for the committee to review. You will be contacted via your UNA email with any additional requests or information. Please contact Housing & Residence Life with any questions.

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