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ACCOMMODATIONS

Disability Accommodation Request Form

NOTE: Do not attempt to complete this form before carefully reading
"How to Request an Accommodation for a Disability"

1. Your Name: * First Name * Middle Name Last Name *
2. Program: *
  Primary Site: *
3.   Anticipated Graduation Year: *
4. Student ID Number:
(if known)
5. Preferred Phone:
6. Preferred Address: Street 1 Street 2: City: State: Zip:
7. VLS Email: *
8. Nature of your disability:
(check all that apply)
Physical Psychological Learning
ADHD Vision Hearing
Other:
                    (Please specify)
9. If you have been diagnosed with a specific condition, please state it here:
10. Date of diagnosis:
(if known)
11. The health care professional who provided—or who will provide—required medical documentation pursuant to the Documentation Guidelines (available here) regarding my condition(s) and accommodations(s) is:
Health Care Professional:

12.

Please upload all documentation required under the pertinent documentation guidelines.

Documentation Guidelines available here)








If you are not uploading medical documentation at this time, please state the reason here (e.g. technical difficulties, documentation not yet obtained, not yet tested, you will hand-deliver or mail, etc.):

13.

Accommodation(s) requested: (check all that apply)

Special exam answer format (e.g. computer only, handwritten only, large print, voice-to-text, etc.)

Additional time for in-class, timed exams

Private exam room

Special Seating Arrangements (e.g. sit/stand requirements, front row requirements, etc.)

Electronic texts and/or text-to-speech readers

Notetaker Services/Class Recordings

Wheelchair Accessibility

Other (please specify):

14.

Past Accommodations

a. Did you receive formal accommodations while you were in college or in other recent academic setting?
Yes     No

b. Have you received accommodations for standardized tests such as the SAT, LSAT, GRE or GMAT?
Yes     No

c. Have you received accommodations at a place of employment?
Yes     No

d. If you answered "Yes" to any questions above, please describe and upload any relevant documentation:
Upload Document:

e. If you answered "No" to all questions above, please state why you are requesting accommodations today: