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Orientation Testing Accommodations Request

A letter about accommodations that I will be receiving during orientation will be sent to a department representative. The accommodation letter will notify these representatives of the accommodations for which I qualify. I understand that the accommodation(s) will be based on medical, psychological and/or educational documentation I have presented to DSS. DSS staff will contact and share information as needed to arrange my accommodations. After receiving my copy of the letter, I agree to meet with the representative or contact the department as soon as possible to discuss the accommodation(s) I will need during orientation.

General Information

Semester/Session:_________________Testing Date: __________

Student’s Name: ________________ SS Number:_______________

Student’s Address/ Telephone Number: _______________________________________________________

_______________________________________________________

_______________________________________________________________

Student’s Email: _______________________________________________

 

Type of Disability

Check all that apply: Mark P for Primary and S for Secondary

___ ADD/ADHD
___ Epilepsy
___ Paraplegia

___ Amputation
___ Head Injury
___ Post Polio

___ Arthritis/Rheumatism
___ Hearing Impairment
___ Psychological

___ Asthma
___ Kidney Disease
___ Quadriplegia

___ Cardiac Condition
___ Learning Disability
___ Respiratory Disease

___ Cerebral Palsy
___ Leukemia
___ Speech Impairment

___ Chronic Pain
___ Lupus _
__ Spina Bifida

___ Cystic Fibrosis
___ Multiple Sclerosis
___ Muscular Dystrophy

___ Diabetes
___ Visual Impairment

___ Diagnosis in Progress (explain): ______________________________________________________________

______________________________________________________________

___ Other (Specify): ______________________________________________________________

PLEASE INDICATE THE ACCOMMODATIONS YOU WILL NEED FOR THIS ORIENTATION BY USING THE FOLLOWING CHOICES.

Alternate Format:

___ Audio Tape	___ Enlarged Print (Size _______Font ______)
___ Braille	___ Other _____________________________
___ Electronic Format

Assistive Technology:

___ Assistive Listening Device	___ Screen Reader
___ Magnification Devices (e.g. CCTV)	___ Speech Recognition
___ Scanning/Reading Solutions (e.g. Kuzweil)	___ Tactile Diagrams
___ Screen Magnification	___ Trackballs
___ Other ________________________________________________________

Classroom Accommodations:

___ Accessible Desk/Table	___ Note taker
___ Braille	___ Priority Seating
___ Classroom/Academic Assistant	___ Scribe
___ Interpreter	___ Tape Recorder
___ Large Print	___ Other ______________________

Testing Accommodations:

___ Alternate Format Answer Sheet (Non-Scantron Answer Sheet for tests)	___ Large Print (Size____ Font ___)
___ Alterative Format for Tests	___ Oral
___ Brailed Tests	___ Reader
___ Calculator	___ Scribe
___ Computer (lab)	___ Separate testing room
___ Computer (laptop)	___ Spell Check
___ Computer (personal adapted)	___ Tape Player / Recorder
___ Extended time on tests	___ Use of Magnification (i.e. CCTV) for In-Class Assignments and Tests

 

Please Note: In order to establish eligibility for services and to enable staff to work more effectively in the provision of services, students must provide documentation of disability to Disability Support. The aforementioned information is provided, so that Disability Support Services can respond appropriately to the individual needs of the student. Disability Support Services reserves the right to determine eligibility for services based on the quality of the submitted documentation. All documentation is confidential.

 

STATEMENT OF CONFIDENTIALITY

All information provided to Disability Support Services is confidential. Only with written consent of the student will information be provided to appropriate offices when information has been deemed necessary to support the individual’s educational and professional pursuits.

I authorize Disability Support Services to release relevant information regarding my disability to persons who have a legitimate educational need to know, and in order to arrange accommodations. Please designate any exception to this release:

Signature: __________________________ Date: ________________

 

Updated: Friday, February 25, 2005

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