Public Accommodation Request

* indicates a required field

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Please use your college issued email address

(note: this is not your 8-digit NetID. The email is the first initial of your first name, followed by the first 4 letters of your last name, followed by 4 numbers @mail.ct.edu. Example: asmit0001@mail.ct.edu)

Phone Number

Specific Accommodation Information

What is your diagnosed disability?

What category do you feel your disability falls into?

How does your disability affect you academically?

How does your disability affect student life on campus, outside academics?

What accommodations have you used in the past?

What is your current status?

What is the best way to get in contact with you?

Upload supporting document(s)

Please prove you are not a robot

Public Accommodation Request

Student Information

Specific Accommodation Information

Document Information