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Employee Disability Accommodation Request Form

Please complete the following form as completely as necessary to document your request. Note that documentation from a medical professional may be required. Form should be submitted the Office of Equity and Access (OEA)
SBU West Campus, RF & HSC, Stony Brook Medicine, and LISVH EmployeesADA Specialist (Attn: Natalie Mertens)
Phone: (631) 632-6280 / Fax: (631) 632-9428 / Email:

Your Information


Impairment Information

Please note that documentation from a medical provider(s) may be necessary

Accommodation Information

NOTE: Attach additional sheets if necessary