Accommodation Request Form

Please complete the following form. You will also need to provide formal documentation to support your accommodation request. Documentation guidelines are available on the Student Accessibility Services (SAS) website (https://www.mbl.edu/education/student-accessibility-services) or by emailing studentaccessibility@mbl.edu. SAS may require further documentation to substantiate the request for accommodations.

This form and supporting documentation must be received before a review by SAS will proceed.

Full Name*

First NameLast Name

Email*

example@example.com

Cell Phone #*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Role at MBL*

Beginning Date of Requested Accommodation*

Date

End Date of Requested Accommodation*

Date

1) Please indicate your diagnosis/condition which is the basis for your accommodation request.*

2) Please list the accommodations you are requesting at MBL, including housing, academic, and/or transportation needs.*

3) Have you ever used any of the above accommodations before? If so, please list the accommodations used before and where they were used.*

4) Explain how your diagnosis/condition requires each of the requested accommodations.*

5) Please indicate if you intend to utilize any of the following while at the MBL:*

Service AnimalMobility Aid (scooter, wheelchair, etc.)Assistive TechnologyOther

Additional Note or Comment:

Please provide documentation supporting your accommodation request - see Documentation Guidelines on the SAS website (https://www.mbl.edu/education/student-accessibility-services).

Signature*

STATEMENT OF CONFIDENTIALITY

The Marine Biological Laboratory (MBL) is committed to protecting the privacy of student education and health records with the means available by law. The MBL will not release information from a student’s education or health record without the student’s written consent, except in the limited circumstances permitted by law. In alignment with the MBL and the law, Student Accessibility Services (SAS) may release a student’s information to other MBL employees/faculty on a need-to-know basis. Additionally, students may request, in writing, information to be released to specific persons or agencies by signing a release-of-information form. Information contained in a student's file (including personally identifiable documentation, correspondence, and accommodation records) in SAS is considered part of their educational record and is protected under the Family Educational Rights and Privacy Act (FERPA), which is a federal law that protects the privacy of student education records. FERPA also protects student health records, including psychotherapy notes and other mental health records. In addition to FERPA, various state laws also protect student health records.

Questions