Student Accessibility Services Local 33 Student Employee Accommodation Request Form

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Background Information

Your Full Name

Position/ Title

Phone Number

Pronouns (optional)

Net ID #

Questions

Help us to learn more about you and your accommodation request.

SAS facilitates accommodation requests for individuals whose relationship with the university falls within the list provided below; please select the category that best fits your relationship with the university. If you are a staff member seeking an accommodation, please complete Human Resources' online intake form available at: https://your.yale.edu/work-yale/benefits/absence-management-and-accommodations-services/staff-accommodations-program.(Required) This field is required.

Please share your specific diagnosis(es).(Required) This field is required.

Please provide a brief explanation of the accommodation(s) you are seeking.(Required) This field is required.

Have you worked with an SAS staff member on this or a related accommodation request in the past?(Required)

Yes No

This field is required.

If so, please share the staff member's name below. This field is required.

Are you currently on an approved leave (medical or planned)? Check all that apply.(Required)

Yes No Medical Leave Dissertation in Absentia Planned Non-enrollment

You must make at least one selection.

Please share your current home address.(Required) This field is required.

Please share your current work address.(Required) This field is required.

Director of Graduate Studies, Principle Investigator, or Supervisor's Name(Required) This field is required.

Health Care Provider's or Specialist's Name(Required) This field is required.

Health Care Provider's or Specialist's Phone Number(Required) This field is required.

Health Care Provider's or Specialist's Email Address This field is required.

By typing your name below, you authorize the Health Care Provider/Specialist named above (or their designee) to communicate with a representative from Yale's Student Accessibility Services office about matters related to your accommodation request and authorize the release of personal health information, as it relates to your accommodation request, via the Health Care Provider/Specialist form.(Required) This field is required.

Please provide your date of birth. This information will only be used to identify you when SAS contacts your health care provider/specialist.(Required)

This field is required.

Please provide your Net ID(Required) This field is required.

If you are requesting a Parking Accommodation and hold a State of Connecticut handicapped permit, please share the number below: This field is required.

Supporting Documentation

Please have your Health Care Provider or Specialist complete the Health Care Provider/Specialist form ; delayed submission of this form will prevent the prompt processing of your request.

If you have a note from your health care provider or specialist that specifies your medical condition and lists any medication(s) used to treat that medical condition, please upload it below.

Your Health Care Provider/Specialist may require a signed authorization for use or disclosure of protected health information before sharing information with OIEA. Yale Health has an Authorization for Use or Disclosure of Protected Health Information form that can be used for this purpose. You may access that form here.

5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Background Information

Questions

Supporting Documentation

Submission