Accommodation Request Form

Please make sure you have reviewed the process for requesting accommodations in full and have reviewed the necessary documentation required for the type(s) of accommodation(s) you are requesting.
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
E Number:
Pronouns:
Phone: Phone: - ### - ### ####
蜜桃影像 Email (please include @eiu.edu)
Alternative Email:
Diagnosed disability for which you are requesting accommodations:
At what age was the diagnosis received?
Have you previously received accommodations?

Have you previously received accommodations? Yes No
What type(s) of accommodations are you requesting?

What type(s) of accommodations are you requesting? Academic Housing
What is the first semester for which you are requesting accommodations? (ex: Spring 2026, Fall 2027, etc)
What specific accommodations are you requesting?
Please upload appropriate disability documentation here (such as an IEP, 504 Plan, Provider Verification of Disability, Provider Verification of Housing Accommodation, etc.):

Attach Files

Documentation guidelines and OAA specific forms can be found on our website.
Will you be submitting additional documentation that has not been attached to this form?
Please read and sign
Confidentiality Notice
The Office of Accessibility and Accommodations at 蜜桃影像 is committed to ensuring that all information and communication pertaining to a student's disability is maintained as confidential as required or permitted by law. The following guidelines about the treatment of such information have been adopted by the OAA and will be shared with students. These guidelines incorporate relevant state and federal regulations. 1. No one will have immediate access to student files in the OAA except appropriate staff of the OAA. Any information regarding a disability is considered confidential and will be shared only with others within the university who have a legitimate educational interest. 2. This information is protected by the Family Educational Rights and Privacy Act (FERPA). 3. Sensitive information in OAA files will not be released except in accordance with federal and state laws. 4. A student's file may be released pursuant to a court order or subpoena. 5. If a student wishes to have information about their disability shared with others outside the university, the student must provide written authorization to the OAA to release the information. The student should also understand that there may be occasions when the OAA staff will share information with institutional personnel regarding a student's disability at their discretion if circumstances necessitate the sharing of information and the OAA staff have determined that there is an appropriate legitimate educational interest involved. 6. A student has the right to review their own OAA file with reasonable notification.
I have been informed of the policy regarding confidentiality and the release of information from my OAA file. I understand that OAA may release information from my file to be used in a confidential manner with appropriate university faculty and officials who have a legitimate educational interest while I am a student at 蜜桃影像.
I understand that accommodations are not considered reasonable if it changes the essential elements of the curriculum or results in undue hardship, considering the nature, cost, and impact of the accommodation. I understand that specific information is required for documentation of disabilities and that accommodations will only be considered after a disability has been verified according to the Office of Accessibility and Accommodations documentation requirements. I have reviewed the appropriate policies and guidelines on the OAA website pertaining to my specific accommodation requests.
I acknowledge that I have read and understand the terms of this agreement as detailed above.
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

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Full Name

I understand this is a legal representation of my signature.
NOTE: This form has been approved for use as of June 1, 2025. The institution reserves the right to update this form, as appropriate, at any time.

蜜桃影像

Accommodation Request Form

Accommodation Request Form

Please read and sign