Request for Reasonable Accommodation or Modification Form

Document Type: 

The purpose of this form is to facilitate a request for a reasonable accommodation or modification. The RA Coordinator will assist the requestor in filling out the form. Any requests made orally have been transcribed by the RA Coordinator onto this form.

NOTE: This form has a "submit" button, but it is only operational if used from within a PDF program.  If, instead, you open this PDF in your browser, you will need to save it and submit it to: and