Accommodation Request

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

G NumberRequired *

Please use format G00000000

EmailRequired *

Please use your university issued email address

Phone NumberRequired *

Example: 123-456-7890

Are you currently enrolled at GVSU?Required *

Are you currently enrolled at GVSU? Yes Are you currently enrolled at GVSU? No

If not enrolled, when do you intend to enroll?Required *

Class StandingRequired *

Will you be receiving financial aid? (grants, loans, and/or scholarships)Required *

Will you be receiving financial aid? (grants, loans, and/or scholarships) Yes Will you be receiving financial aid? (grants, loans, and/or scholarships) No

Are you an international student?Required *

Are you an international student? Yes Are you an international student? No

Are you employed?Required *

Are you employed? Yes Are you employed? No

How many hours per week do you work?Required *

Disability Information

Please check any disability conditions that applyRequired *

ADHD
Autism Spectrum Disorder (ASD)
Chronic Illness
Hearing Impaired/Deaf
Learning Disability
Mobility Impairment
Physical Disability
Psychological Disability
Traumatic Brain Injury (TBI)
Visual Impairment/Blind

Please explain any other disabilities

Please list any prescribed medication related to your disability

Specific Accommodation Information

What type of accommodations do you use to assist you at university or home?Required *

Are you requesting housing accommodations?Required *

Are you requesting housing accommodations? Yes Are you requesting housing accommodations? No

Are you requesting accommodations for study abroad?

Are you requesting accommodations for study abroad? Yes Are you requesting accommodations for study abroad? No

How did you learn about the DSR?

Please check all that apply

DSR Website
Union Representative
Ombudsperson
Supervisor/Unit Administrator
Human Resources
Office of Inclusion and Equity
Other

Upload supporting document(s)

Documentation of a disability must appear on official letterhead from a licensed physician, psychiatrist, social work, or other mental health professional with their License/Certification number & State of licensure and include:

1. A specific statement of the diagnosis / diagnoses.
2. A summary of related functional limitations

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Accommodation Request

Student Information

Disability Information

Specific Accommodation Information

Document Information