Special Provision Declaration Form
Submit your request for special provisions or accommodations with all required details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Affiliation
*
Type of Special Provision Requested
*
Please Select
Exam Accommodation
Workplace Adjustment
Deadline Extension
Remote Participation
Other
Please provide a detailed description of the special provision you are requesting.
*
Reason or Justification for Request
*
Effective Date for Special Provision
*
-
Month
-
Day
Year
Date
Duration or End Date (if applicable)
-
Month
-
Day
Year
Date
Upload Supporting Documents (if any)
Upload a File
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Choose a file
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Additional Comments or Notes
Signature
*
Submit Declaration
Submit Declaration
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