Winston-Salem State University Faculty or Staff Accommodations Request Form

Winston-Salem State University is committed to compliance with the Americans with Disabilities Act (1990) the American with Disabilities Amendments Act (2008), and Section 504 of the Rehabilitation Act (1973). The purpose of this form is to assist Winston-Salem State University in determining whether, or to what extent, a reasonable accommodation will allow an employee to safely and effectively perform the essential functions of his or her job.

This form is to be completed by the Winston-Salem State University Faculty or Staff member that is seeking accommodations through the WSSU Department of Disability Services.

Place a check mark inside each check box to affirm the following:

I certify that I am the faculty or staff member requesting services.

I certify that I am initiating an accommodation request and disability eligibility review.Remember me.

I understand that the documentation for reasonable accommodations varies based on the disability and circumstances (essential functions/criteria), and that I am responsible for verifying what documentation is needed.

I understand that I am responsible for all cost associated with obtaining the reports, examinations, tests, etc.

I understand it is my responsibility to share comprehensive and appropriate documentation to the Department of Disability Services.