Public Accommodation Request

* indicates a required field

Student Information

First semester at UMass Lowell (e.g. Fall 2019)

Are you registering for a temporary disability that is expected to last less than 6 months (e.g recent concussion, broken limb)?

First Name

Last Name

Middle Name

Preferred Name

Student ID

You must use your university issued email address

Preferred Phone Number

Specific Accommodation Information

My diagnosed disability falls into the following category

If you selected "other" for the previous question, please specify

What Accommodations have worked for you in the past?

Please list any disability medication you are currently taking.

How does your disability affect your daily life?

How does your disability affect you academically?

Please share any other information that you feel would be helpful to SDS.

Functional Limitation

Please select the extent to which you believe your diagnosed condition affects the following major life activities.

Caring for oneself

Talking

Hearing

Breathing

Seeing

Walking/Standing

Lifting/Carrying

Sitting

Performing Manual Tasks

Eating

Working

Learning

Reading

Writing/Spelling

Calculating

Memorizing

Concentrating

Listening

Other

Did you attend a college or university prior to UML?

Upload supporting document(s). See website for documentation requirements

Please attach documentation if available. Documentation can also be provided by email. The process will not move forward until documentation is received. Documentation Guidelines.

The Disability Services Office provides academic access to students, therefore the following forms do not fall under the purview of the Disability Services office. These forms WILL NOT be reviewed if submitted here:

Housing for Medical Reasons
Animal Request Forms
Meal Plan Requests
Medical Withdrawal forms

Please refer to these forms for the process on how to submit them.

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