Accessibility Resource Center
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Orientation Testing Accommodations Request Form

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: ________________