Accommodation Planning Request | Institutional Equity and Compliance

Alternate versions of this form are available upon request. Contact us by email at access@unl.edu or by phone at 402.472.3417.
Upon completing this form, you will receive an automatic email acknowledgment. After we receive your request, someone will from our office will make contact with you within a few business days.

Webform

Personal Contact Information

First Name Required

Last Name Required

Date of Birth Required

Home Address Required

City Required

State Required

Zip Required

Home Phone Number Required

Email Address Required

Supervisor Information

Supervisor Name Required

Supervisor Address Required

Supervisor Phone Required

Accommodation Request

What is the condition for which you are requesting an accommodation? Required

Department Contact Information

Position Title Required

Department Name Required

Department Address Required

Department Phone Required

Do You Have a Copy of Your Job Description?

Yes (Please Upload a Copy Below)

Job Description

One file only.
20 MB limit.
Allowed types: rtf, pdf, doc, docx.

Please list the accommodations or items you believe would be reasonable and helpful in allowing you to perform the essential functions of your position Required

Can you be contacted at the department phone during work hours? Required

Webform

Title IX Coordinator Meagan Counley