Temporary Medical Accommodation Request Form

Temporary Medical Accommodation Request Form

In the spirit of Jacksonville University’s mission and values, the institution will review and consider student requests for special accommodations for those with temporary medical needs. A few important notes:

- This request form is for medical-related accommodation requests, and supportive medical documentation must accompany your request. This supportive documentation should be a letter from your medical provider (on their letterhead) that establishes the need and the reason for the requested accommodations. The documentation should also detail any pertinent or requested accommodation that could/would provide you the necessary support.
- This request form is for accommodations related to a medical need for the semester.
- Please include any and all information related to your request.
- If the requested accommodation is approved, it will be approved for one semester only.

Name Name First Last
JU ID#
Email
Phone Phone - ### - ### ####
Do you wish to request or renew an accommodation due to a medical need (considering Covid-19 circumstances)? The CDC outlines a number of medical factors that increase a person's risk of severe illness from COVID-19.

Do you wish to request or renew an accommodation due to a medical need (considering Covid-19 circumstances)? The CDC outlines a number of medical factors that increase a person's risk of severe illness from COVID-19. Request Renew
Were you granted accommodations during the most recent term through Disability Support Services?

Were you granted accommodations during the most recent term through Disability Support Services? Yes No
What types of accommodations were you granted for the most recent term?

What types of accommodations were you granted for the most recent term? 100% online classes Exemption from campus residency requirement Other Other
What types of accommodations are you interested in exploring for this semester? Select all that apply.

What types of accommodations are you interested in exploring for this semester? Select all that apply. 100% online classes Exemption from campus residency requirement Other Other
What or where is your current housing situation or location?

What or where is your current housing situation or location? On-campus residence Off-campus residence (local to Jacksonville) Off-campus residence outside of Jacksonville (Please provide city, state, and country.)
What is your current year of study?

What is your current year of study? Freshman Sophomore Junior Senior Graduate level
What is your major?
Supportive Medical Documentation

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