Request for Disability Accommodation

Missouri State University is committed to providing an accessible and supportive environment for employees and students with disabilities. Please tell us if you require a reasonable accommodation to perform your job. A request for accommodations will not be used against you in any way, and the information you provide will be safeguarded. All university employees have a legal obligation to maintain confidentiality regarding a staff or faculty member’s disability-related information. To that end, supervisors and representatives from the Office for Institutional Equity and Compliance shall provide information to staff and faculty only when necessary to facilitate accommodations.

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Personal information

MSU Affiliation*

Personal pronouns

Title

First name*

Middle name

Last name*

Street address

City

State

Zip code

Preferred method of contact*Please tell us how you prefer to be contacted.

Phone number*Please provide your phone number or "N/A" if not applicable.

Email address*Please provide your email address or "N/A" if not applicable.

Employee/Student Information

BearPassPlease provide your BearPass # if you are an employee or student.

Job titlePlease tell us your job title if you are an employee.

DepartmentPlease tell us which office or department you work for if you are an employee.

SupervisorPlease tells us the name of your supervisor if you are an employee.

Accommodation Information

Please be as specific as possible (e.g. adaptive equipment, reader, interpreter).

Accommodation Requested*What accommodation(s) are you requesting?

Reason for accommodation request*Why are you requesting the specified accommodation(s)?

If accommodation is time sensitive, please explain

Acknowledgement

By submitting this form, I acknowledge that the information presented on this form is accurate.