Texas Woman’s University

Office Of Human Resources

American’s with Disabilities Act (ADA)

Accommodation Request Form

Print Name: ______________________________________       Signature: _____________________________________

Title: ___________________________________________        Today’s Date: __________________________________

Department: _____________________________________         Campus: ______________________________________

Phone Number: __________________________________          E-mail Address: ________________________________

Describe the impairment _____________________________________________________________________________

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Provide or describe the evidence of disability at the request of the ADA Officer.

Describe the accommodation needed (please be specific) _____________________________________________________

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Please forward a completed copy to your immediate supervisor and send this original form to the ADA Officer in the Office of Human Resources.  The ADA Officer, or his/her designee, may request additional information to further consider your request.