Request for Accommodations

Request for Accommodations
Trine University is committed to providing students with disabilities equal access to its educational opportunities and programs. Trine’s Policy on Disability and Accessibility is implemented in the context of the Americans with Disabilities Act (ADA) of 1990 as amended, Section 504 of the Rehabilitation Act of 1973 (Section 504); the term “disability” may include learning, physical, sensory, psychological, medical, and specific temporary disabilities. The University provides students with reasonable accommodations by the ADA/Section 504 and applicable state law. Students with disabilities may request academic accommodations, housing and dining accommodations, modifications to University policies, rules, and regulations, environmental adjustments such as removing architectural, communication, or transportation barriers, and auxiliary aids and services. For services and requirements, visit the Trine University website at https://trine.edu/campus-life/health-wellness/accessibility-and-accommodations.aspx.
Trine Student ID Number
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Trine Student Email Address
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Location*
Student Full Name*

First NameMiddle NameLast Name
Student First Name*
Student Middle Name
Student Last Name*
Legal Name (if different)

First NameMiddle NameLast Name
Student Phone Number*

Country CodeArea CodePhone Number
Class Year*
Today's Date

MonthDayYear
Date
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Category of Request (check all that apply)*

HousingDietaryService AnimalAcademic SupportEmotional Support AnimalOther
Functional Impact
How does your disability impact your ability to complete coursework or other program requirements? *
How does your disability impact your daily activities outside the classroom? *
Prior Academic Accommodations
Were you approved for accommodations in a prior academic setting? *
Current Accommodation Requests

Please explain below the category of the accommodation request, the nature of the accommodation request, and your rationale for the need for each accommodation you wish to request. After entering your first request, you will be prompted to provide the same information for each additional request.
Detailed Nature of Request*
Upload Supporting Documentation for Request*

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Certification and Permission
Under the Family Educational Rights and Privacy Act (FERPA), the Office of Disability Services (ODS) may share information and communicate with appropriate University personnel on a need-to-know basis to facilitate the process of determining accommodation eligibility and implementation. In addition, the Office of Disability Services’ evaluation may include a review of your documentation by an external consultant engaged by the University. In limited circumstances, specific information maybe required to be disclosed to protect individuals in an emergency or to comply with the law and University policies and procedures. The information on this form may be used in the aggregate for reporting purposes.*

Permission Agreement YesPermission Agreement No
I understand that my accommodation request(s) cannot be considered until appropriate documentation is submitted. I know Trine University uses the information on this form as stated above. If I responded affirmatively above, I am permitting my treating professional to be contacted, if necessary, to determine accommodation eligibility.

By clicking submit, I acknowledge that I am the individual stated in the application and that the information provided is true, accurate, and complete.
Should be Empty:

Request for Accommodations

Functional Impact

Prior Academic Accommodations

Current Accommodation Requests

Certification and Permission