Winston-Salem State University Logo

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: