I am requesting a short-term health related academic accommodation(s) for the term and course(s) specified above. I have requested that my medical treatment provider submit a written recommendation to the Office of Health & Counseling Services for consideration. I further acknowledge that my request must be approved by the Office of Health and Counseling Services and by my instructor(s). Simply filing this request form does not mean that a short-term health related academic accommodation(s) has been granted. The Office of Health & Counseling Services will contact me at my EIU email account letting me know of their decision. If my request for a short-term health related academic accommodation(s) is approved, it is my responsibility to work with each instructor to implement the agreed upon accommodation(s). Furthermore, I acknowledge that I must apply for this accommodation(s) each term as my classes, instructors, and needs will change.