Temporary Accessibility Accommodations Request Form

The Office of Accessibility Services assists students with temporary disabling conditions (6 mos or less) that are a result of injuries, surgery, or short-term medical conditions who may need accommodations or access to services and resources. Examples of temporary disabilities may include, but are not limited to: broken limbs, hand injuries, concussions, or other short term impairments following surgery or medical treatments.

To receive accommodations for a temporary disability, the student must complete and submit this form (deliver or scan/email) as soon as possible to the Disability Services Coordinator indicating the type of disability, severity, limitations, prognosis, and estimated duration of the disabling condition. Professional documentation in accordance with Disability Services Policy may be required and should be recent enough to identify current limitations and the estimated time of healing. The Coordinator will advise the student of approved accommodations and will communicate with university personnel as needed to coordinate services.

Note: Requests for Temporary Handicap Parking Permits must be submitted directly to Medical Director along with a physician note stating the need for temporary handicap parking access and the estimated required time frame.

Name

First NameLast Name

Student ID or Birthdate

Residence Hall Address

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Classification:

Athletic Team (if applicable)

Athletic Trainer (if applicable)

What is the nature of the disability you are requesting accommodations for?

In your own words, please describe the current impact and functional limitations of the disability (i.e., physical and or mental):

What is the duration of your condition and how long do you anticipate needing accommodations:

Accommodations requested at Mars Hill University (check/explain those appropriate to you and complete the additional questions below, if needed):

If you selected YES for option 2 please provide the instructor(s) name:

If you selected YES for option 3 please provide the name of friend(s):

If you selected YES for option 4 please describe requested accommodations:

Reasonable accommodations are intended to minimize the impact of specific limitations caused by a disability in order for a qualified individual to have equal access to programs, services, and activities. Individuals will be contacted via MHU email address regarding their eligibility status.

INFORMATION EXCHANGE/DISCLOSURE STATEMENT: If applicable, I give the Office of Accessibility Services (OAS) permission to consult with infirmary staff or athletic trainer at Mars Hill University in order to assist with the evaluation of my medical documentation. Information will be shared as needed with university personnel in order to receive requested services. I understand that this information will be kept confidential to the extent permitted by law.

Signature

Date

Kirby Knight
Director of Collegiate Recovery and Accessibility Services
Nash 309
Phone: (828) 689-1188
Email: kirby_knight@mhu.edu