UT Housing AccommodationRequest Form

UT Housing Accommodation

Request Form

This form is to be used by students who are requesting disability-related accommodations in UT Housing. This information and the student’s signature are required so Disability and Access (D&A) staff have permission to speak with University Housing and Dining (UHD) and/or New Student Services (NSS) if accommodations are being requested for orientation.

More information about the housing accommodation process and required documentation can be found at the following link: https://disability.utexas.edu/housing/

This form is only to be used to request housing accommodations required because of a disability and supporting documentation from a healthcare provider must be submitted before this form will be processed. Non-disability related requests should be directed to University Housing and Dining.

Requests for dining accommodations should be directed to the UHD Registered Dietitian: dietitian@austin.utexas.edu.

Student Name*

(first and last)

Student EID*

Date of Birth*

Student email address*

Student phone number*

Phone

I am requesting a housing accommodation starting in this semester*

(please write semester and year you would first like to use housing accommodations)

Will you require this accommodation during summer orientation?*

Yes

Will you require assistance in case of evacuation in the residence halls?*

Yes

What is the Housing Accommodation being requested*

If this accommodation is for someone other than the enrolled student, please list their name and relationship to the student

Please explain why the requested housing accommodation(s) are necessary to provide you with equal access to your living environment on campus based on the impact of your disability*

Electronic Signature: By typing my signature I affirm that all personal statements and documents that I am submitting in support of my request are true and correct. I understand that falsifying or misrepresenting facts or information may result in disciplinary action. I authorize Disability and Access staff to release disability related information to University Housing and Dining and/or New Student Services as it relates to my request for housing accommodations.*

Send me a copy of my responses

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