Accessibility Request for Accommodations Form at MSUM

Complete and submit this form in its entirety.

I have reviewed the Rights and Responsibilities. My submission of this form signifies I have read and agree to my Rights and Responsibilities.

If you are requesting an Emotional Support Animal (ESA) as an accommodation, please go to the ESA request form.

* indicates required field

Name:*

Dragon ID:*

Mnstate.edu Email Address:*

All official University business will be conducted via MSUM email accounts. It is essential that you access, read and use your go.mnstate.edu account.

Phone:*

Are you living on campus?* Yes No

Reason for applying:* Classroom/Academic Accommodations Housing/Dining Accommodations Temporary Accommodations Other

Diagnostic Information

Please identify any disability/disabilities that you have been diagnosed with:* Learning Disability (ADHD) Physical Impairment Deaf/Hearing Loss Blind/Vision Loss Medical Psychological Other (Unknown/Undiagnosed)

History of Accommodations

Please describe the accommodation(s) you have received in the past. If none, please put N/A.*

Please list the accommodations you are requesting (e.g. adaptive equipment, alternate format, note taking, exam accommodations, sign language interpreter, etc.). Please include the accommodation(s) requested, as well as the reason for that accommodation.*

Documentation from a qualified professional must be shared with Accessibility Resources.

This application for services was completed by:*

If you do not receive a copy of this form in your email that this form was submitted successfully, please contact the Accessibility Resources Office.