Initial Request for Disability Accommodations

Instructions

Please use this form if you are requesting accommodations/services for the first time. Please complete all information. Documentation of your disability must also be submitted to complete your request for services. Please see the documentation guidelines for the specific required documentation.

Personal Information

First Name

Middle Name

Last Name

include Jr., Senior, etc.

Date of Birth

Age

Gender

Ethnicity

UNTD Numerical ID

(EMPLID)

Cell Phone Number

If you do not have a cell phone number, please input "n/a".

Ok to phone?

Ok to message?

Home or Other Phone Number

If you do not have a cell phone number, please input "n/a".

Ok to phone?

Ok to leave a message?

UNTD Email Address

Please use your university issued email address

Preferred method of contact

Emergency Contact

Name

Relationship

Phone

(###) ###-####

Street Address

Apartment #

City

State

Zip Code

Other Information

Check yes for those groups that apply to you and answer the corresponding follow-up questions.

Veteran

International Student

Country

Transfer Student

First Generation Student

Academic Information

Academic Status

First semester for which you are requesting accommodations

Course load for semester

Input number of credit hours

UNTDallas GPA

Undergraduate GPA, Graduate GPA, or Law GPA

Disability Information

My diagnosed disability falls into the following category

Please note that if you have a condition that has not been present for more than 6 months or is not expected to affect you for more than 6 months, this is not covered under disability legislation. Disability Services will work with these individuals to accommodate their needs, though.

When was your disability originally diagnosed?

Do you receive services from the following agencies?

Accommodation History

List all accommodations you used BEFORE coming to UNT Dallas. Please describe the accommodation, where it was used and when:

If applicable, list all accommodations that you have used since attending UNTD. Please describe the accommodation, where it was used and when:

Did you receive accommodations on a state mandated or higher education entrance exam (i.e., SAT, ACT, GRE, GMAT, and LSAT)?

Accommodation Requests

Please list the accommodations that you are requesting at UNT Dallas.

Please note that your documentation of disability must support these requests.

By my signature below:
I am requesting reasonable accommodations for my disability (disorder, Illness, or condition). I understand that in order to receive reasonable accommodations, I must submit current documentation of my disability, disorder, illness or condition (guidelines are provided) to Disability Services, be found eligible for accommodations/services, and MUST request reasonable accommodations in a timely manner. I understand that I must submit request for accommodations for each semester. I certify that to the best of my knowledge, the information that I have provided is complete and accurate.

I also certify that I understand that accommodations determinations by UNT Dallas do not guarantee that any particular accommodations will be granted by anyone outside of the University including but not limited to other learning institutions or testing entities such as a State Bar or licensing agency.

Signature

Please type your name in this field

Upload supporting document(s)

Click here to access forms to share with your providers for documentation of disability.