ADA Reasonable Accommodation Request

ADA Reasonable Accommodation Request

Please complete the below form and submit. All required fields are noted with a red *. If you are unable to complete the form, or your request relates to a meeting that is scheduled within two weeks of today's date, please contact ADA@ncseaa.edu.

Last Name*

First Name*

Middle Name (Optional)

Phone Number*

Phone

Email*

Preferred Method of Communication*

Select or enter value

Date of Accommodation*

On what date do you need accommodation provided?

Time*

At what time is the accommodation needed?

Estimated Duration*

How long will you need your accommodation/what is the estimated duration of your meeting?

Select or enter value

Describe the Type of Accommodation Needed*

Please describe the type of accommodation you are requesting.

Type of Meeting

Select or enter value

Additional Information

Please provide any additional information you feel will help us better accommodate you.

Supporting Documents

Upload any additional information that you believe will be helpful.

**Please do not include any personal identifying information including social security numbers, birth date, or any other sensitive information not included on this form.**

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse