Public Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

This must be your Tufts numerical student ID.

Pronouns

Tufts Email

Please use your university issued email address.

Cell Number

Where do you live?

Are you a Tufts student athlete?

Are you a protected veteran?

Are you an international student?

Academic Information

Is this your first semester at Tufts?

Are you a transfer student?

School enrolled or interested in

Are you a full-time or part-time student?

What Summer Program are you enrolled in?

If you are not enrolled in a Summer program, please skip this question.

What is your major; or what do you think your major will be?

What is your minor; or what do you think your minor will be?

What is your anticipated year of graduation?

Confidentiality Notice

As you complete this form, please be aware that as university officials, Student Accessibility and Academic Resource (StAAR) Center staff are mandated reporters.

This means that if a student self-discloses experiences related to sexual misconduct, relationship violence, and/or harassment, that they are required to connect that student to support resources in the Tufts Office of Equal Opportunity. Next steps after this referral are completely in the hands of the student. For questions, please contact the StAAR Center at 617-627-4539 or StAARCenter@tufts.edu.

Disability Information

Please describe your disability/ies).

Disabilities we work with include:

Hearing, vision, speech, or mobility impairments
Learning disabilities
Serious medical or mental health conditions
Temporary conditions such as injuries or broken bones

Is your disability

When was your disability initially diagnosed? (approximate)

If temporary, how long is it expected to impact you?

Have you given StAAR your clinical documentation?

Students need to provide clinical documentation to accompany their request. For more information, visit our website.

Please upload supporting documentation.

Students need to provide clinical documentation to accompany their request. For more information, visit our website.

List any current treatments for your disability (such as medication, counseling, physical therapy, etc.)

Accommodation Information

Please describe the accommodations that you are interested in seeking

StAAR provides accommodations in both academic and non-academic (such as housing, dining, or transportation) spaces. Please include information about both academic and non-academic accommodations on the same form, if applicable.

In your own words, please describe the nature of your condition and how it may impact your Tufts experience

Appointment/Follow-Up Information

How did you hear about us?

What other resources would you like us to help connect you to?

Confidentiality and Disclosure of Information

Please read the following:

1. All information maintained by the StAAR Center is part of a student’s educational record and as such protected by the Federal Family Educational Rights & Privacy Act (FERPA).

2. 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.

3. 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 StAAR Center.

4. The StAAR Center office strongly advises students to keep a copy of their documentation.

5. Registration with the StAAR Center and/or the use of accommodations does not appear on student’s transcripts from the university.

6. Disclosure to the StAAR Center does not constitute disclosure to other offices, services, or professionals at Tufts University.

7. In order to use academic accommodations in a course, a student must disclose their accommodations approved by the StAAR Center to the Faculty member of record for that course.

8. Information is only shared with other professionals at Tufts University to facilitate the provision of accommodations when necessary and/or if questions arise.

9. Information pertaining to a student’s diagnosis will not be shared with other professionals at Tufts University without written consent from the student.

10. Students requesting release of information must fill out and sign a consent form.

11. When a student has graduated or is no longer a student at Tufts University, the student’s file is archived.

Please reach out to the StAAR Center at 617-627-4539 or StAARCenter@tufts.edu with any questions or concerns.