Employee Request for Disability Accommodation

Missouri State University is committed to providing an accessible and supportive environment for employees and students with disabilities. Please tell us if you require a reasonable accommodation to perform your job. A request for accommodations will not be used against you in any way, and the information you provide will be safeguarded. All university employees have a legal obligation to maintain confidentiality regarding a staff or faculty member’s disability-related information. To that end, supervisors and representatives from the Office for Institutional Equity and Compliance shall provide information to staff and faculty only when necessary to facilitate accommodations.

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Employee information

Personal pronouns

Title

First name*

Middle name

Last name*

Street address

City

State

Zip code

Preferred method of contact

Phone number

Email address

BearPass

Job title*

Department*

Supervisor*

Accommodation Information

Please be as specific as possible (e.g. adaptive equipment, reader, interpreter).

Accommodation Requested*

Reason for accommodation request*

If accommodation is time sensitive, please explain

Acknowledgement

By submitting this form, I acknowledge that the information presented on this form is accurate.