Accessible Transportation Request Form
Office of the Assistant to the President
UNIVERSITY DISABILITY SERVICES
Human Resources Representative
Work/Housing address on campus (if applicable)
Briefly describe your functional limitations
Are your functional limitations permanent or temporary; and if so, for how long?
Do you use a wheelchair or scooter?
Are you able to walk?
What is the maximum distance you are able to walk?
A few steps - less than 10 feet
50 feet or less
100 feet or less
I have no walking restrictions
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
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