Accessible Transportation Request Form
University Disability Services
Employee Name *
Your answer
Affiliation/School
Your answer
Department/Unit
Your answer
Job Title
Your answer
Preferred phone
Your answer
Preferred email
Your answer
Manager/Supervisor
Your answer
Human Resources Representative
Your answer
Work/Housing address on campus (if applicable)
Your answer
Briefly describe your functional limitations
Your answer
Are your functional limitations permanent or temporary; and if so, for how long?
Your answer
Do you use a wheelchair or scooter?
Are you able to walk?
What is the maximum distance you are able to walk?
Employee Signature
I understand that I am responsible for providing medical documentation from my health provider(s) which substantiates my functional limitations and expected duration.
My typed name indicates my digital signature *
Your answer
Date *
MM
/
DD
/
YYYY
Submit
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