Public Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Email

Phone Number

Specific Accommodation Information

What is your diagnosed disability?

Please check off both your primary and secondary diagnosed disabilities

Plea

Did you receive special education services (IEP/504) in grade school or high school?

What supports do you feel would be most beneficial to help you succeed in college?

Student self-report

How does your disability impact the academic setting?

(Examples: test taking, class attendance, taking notes, understanding materials, speaking, comprehension, etc.)

Are there any other areas of College life that might be impacted by the disability

(Examples: transportation, building accessibility, parking, etc.)

What adjustments have you used in the past? What was helpful? What was not?

extended time on exams, notetaker, quiet room, etc.

What assistive technology devices/auxiliary aids have been effective in providing equal access to educational opportunities?

Example: Tape Recorder, Calculator, Audio textbooks etc.

What is your intended major? Are there specific adjustments that need to be explored in that course of study?

Are you working with any external support networks or organizations

Vocational Rehabilitation Services, Veterans Services, Bureau of SVS. For Visually Impaired, Other

Have you been prescribed medication applicable to your disability? How does the medication impact your daily functioning?

What are your strengths?

What are your challenges?

Is there any additional information which you would like to include

What is your current status?

What is the best way to get in contact with you?

Upload supporting document(s)

General Guidelines

All students must present current, appropriate documentation to support their requests for accommodations that meet the guidelines of the Americans with Disabilities Act (ADA 1990), the Americans with Disabilities Amendments Act (ADAA 2008), and Section 504 of the Rehabilitation Act (1973). Accommodations can be made going forward from the time documentation is presented to and accepted by the Disability Support Services Office (DSS).

Classroom accommodations are arranged through presentation of an Academic Adjustment Form. The form is prepared based upon the information provided by the individual’s documentation. The form is signed by the student and the DSS coordinator and is presented to the instructor at the beginning of each semester. Each semester the student must secure a new form for each class in which he/she is registered.

I understand the General Guidelines

Academic Dishonesty

A student who is found cheating will be reported to the instructor. That student will then have his/her testing services suspended and will not be reinstated until a conference between the student, the Disability Support Services Coordinator and the instructor is held.

Examples of cheating include:

Copying from another student’s test or assignment.
Using the textbook, course handouts, notes or taped information during a test without instructor permission
Failing to follow test-taking procedures, including talking during the test, ignoring stopping and starting times, or other disruptive activity.

Acknowledgement of Academic Dishonesty

I have read or I have had this form read to me and I understand the above rules. I further understand that any violation of this test proctoring agreement may result in the suspension of test proctoring services. I have been given the opportunity to ask questions. I agree to comply with the rules.

Consent

This is an Information Disclosure Consent Form to be maintained in compliance with the Family Education Rights and Privacy Act (FERPA, 1974, 2008)

When a student who is 18 years of age or older, enters college, all parental rights regarding education afforded to parents are transferred to the student In compliance with the above stated Federal Laws. However, the student may elect to keep parents, medical professionals, and other designated individuals informed of his/her term grades, overall GPA, progress in a degree program, academic advising/transfer information, and compliance with the disciplinary code of the college.

Under Federal Law, the signed document authorizes, but does not require, the Disability Support Service Provider to disclose information maintained in confidential records, if in the judgment of the Disability Service Provider, it is determined to be inappropriate to disclose such information.

Information Types

Additional Permissions

Permission for DSS Provider to dialogue/advocate with faculty on my behalf:

Person(s) to whom I authorize release of confidential information:

Include Name, Phone (with area code) and Relationship to Student

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