Public Accommodation Request

* indicates a required field

Disability Registration and Reasonable Accommodation Request Form

Are you a student or an employee?

Student and employee fields will generate in the form based upon your selection

Preferred PronounsRequired *

First NameRequired *

Last NameRequired *

Middle Name

UNI

required for staff and students

Teachers College EmailRequired *

If you have a TC email please use that, if not, use your personal email

Home Phone NumberRequired *

Work Phone Number

Cell Phone

Fax

Department

TitleRequired *

Supervisor NameRequired *

Supervisor's phone

Supervisor's email

Academic DepartmentRequired *

Program of StudyRequired *

Degree

Program State DateRequired *

Please provide semester, year (ex. Fall, 2020)

Please list previous colleges attended, dates and degrees

Be sure to include that name of each institution, dates attended as well as any degrees earned. For example, SUNY, 2010 - 2014, BA.

Name of emergency contactRequired *

Relationship of emergency contactRequired *

Emergency Contact Phone Required *

Emergency Contact EmailRequired *

Disability Information

Please identify your disability

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Other Disability

This disability is

In order for us to serve you better, please describe your disability. Include age of onset. Required *

In addition, please provide medical documentation from within the past five years.

What type of accommodations have you used in the past, if any?Required *

What type of support services have you used in the past, if any?Required *

Please identify the limitation(s) that impacts your ability to complete your assigned tasks.Required *

Please be specific.

Accommodation RequestRequired *

Please describe the nature of the accommodation requested and how the accommodation will assist you to perform the essential functions of the job held, or to enjoy the benefits and privileges of employment. Please be specific and attach additional sheets and supporting documentations as appropriate. If equipment is requested, please specify preferred brand, model number and vendor, if known.

Are you a New York state resident?

Are you a New York state resident? Yes Are you a New York state resident? No

Do you have an open case with ACCESS-VR or CBVH?

Vocational Rehabilitation or Commission for the Blind and Visually Handicapped

Do you have an open case with ACCESS-VR or CBVH? Yes Do you have an open case with ACCESS-VR or CBVH? No

Counselor Name

Counselor Phone

Additional Information you feel is important for OASID to be aware of

Documentation

You will be required to provide medical verification documentation by a health professional or a disability service provider (e.g.) ACCESS-VR, NYS Commission for the Blind and Visually Impaired). This confidential documentation is to be provided to the director of OASID.

Medical verification documentation should, to the extent possible:

Be written on the official letterhead of the qualified health professional or health professional's organization, and identify the health professional's credentials. E.g., M.D., D.O.
Be dated and signed by the health professional.
Describe the limitations in detail as they currently exist and only in relation to the job.
State whether the duration of the limitation is permanent or temporary or unknown.
If temporary, specify the date the limitation is expected to no longer require accommodation.

Upload supporting document(s)

Digital SignatureRequired *

I certify that I have read and understood the information provided in this request, and that it is true to the best of my knowledge, information and belief.

Date Signed

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Public Accommodation Request

Disability Registration and Reasonable Accommodation Request Form

Disability Information

Document Information