Public Accommodation Request

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Student Information

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First Name

Last Name

Middle Name

Pronouns

Student ID

Please use your university issued email address

Phone Number

Class Year

Disability Information

Please describe your challenges and/or disability(ies):

Date your disability(ies) was first diagnosed:

Is your disability (please select):

Upload supporting document(s)

Often times, we will eventually need medical documentation of your medical condition if your medical documentation is available, please attach it here.

Please list any current treatments for your disability (medication, counseling, physical therapy, etc.)

Accommodations Information

Have you received accommodations in the past? If so, please describe what worked well.

Are there other (new) accommodations you are interested in seeking/requesting?

If you have not received accommodations in the past, please describe what you feel would be needed at this time.

In your own words, please describe the nature of your condition and how it may impact your experience at the Cummings School.

Are there other resources you would like us to connect you to?

Confidentiality and Disclosure of Information

All information maintained by the Student Affairs Office and Accommodation Administrator is part of the student’s educational record and as such protected by the Federal Family Educational Right & Privacy Act (FERPA).

Students wishing to waive their FERPA rights and allow information in their educational record to be shared with someone other than themselves must fill out and sign a FERPA release with the Registrar.
Documentation pertaining to a student’s diagnosis (including, but not limited to, diagnostic evaluations, IEPs/504 plans, medical records, etc.) should only be submitted to the Student Affairs Office or Accommodation Administrator.
It is strongly recommended that the student maintain a copy for their own documentation.
Registration with Student Affairs and/or use of accommodations does not appear on the student’s transcripts from Tufts University Cummings School of Veterinary Medicine.
Disclosure to the Student Affairs Office does not constitute disclosure to other offices, services, or professionals at the Cummings School of Veterinary Medicine.
Information is only shared with other professionals at the Cummings School of Veterinary Medicine to facilitate the provision of the accommodation when necessary and/or if questions arise.
Information pertaining to a student’s diagnosis will not be shared with other professionals at the Cummings School of Veterinary Medicine without written consent.
Students requesting release of information must fill out and sign a consent form.
When a student has graduated or is no longer a student at the Cummings School of Veterinary Medicine, the student’s file is kept for no more than 5 years, and then destroyed.
As university officials, Student Affairs faculty and staff members are mandated reporters. This means that if a student self-discloses recent suicide ideation, recent suicide attempts, experiences related to sexual violence, relationship violence, and/or harassment that they are required to connect that student to support resources. The next steps after referral are completely in the hands of the student.

Please initial that you have read, understand, and agree with the above.

Public Accommodation Request

Student Information

Disability Information

Accommodations Information

Document Information