Page 1

Contact Information

First Name	Last Name
Student ID Number	Date of Birth
Email Address	Mobile Number

Current Academic Level

Living Information

Where are you living this year?

On CampusOff Campus

What is your room number?

What dorm do you/will you live in?

Off Campus Street Address

i.e. 1348 Walnut St. #2

Off Campus City

Off Campus Zip

Off Campus State

What Term is this accommodation for?

Accommodation Request Information

Please select your primary disability.

Acquired Brain InjuryADD/ADHDAutism Spectrum Disorder (ASD)Blind/Visual ImpairmentDeaf/Hard of HearingDevelopmental DisabilityHealth ImpairmentLanguage ImpairmentLearning DisabilityOrthopedic ImpairmentPsychiatric Disability (anxiety, depression)Speech ImpairmentOther (please specify)

Other Primary Disability

Primary Learning Disability Specification

Please select any secondary disabilities.

Acquired Brain Injury	ADD/ADHD	Autism Spectrum Disorder (ASD)
Blind/Visual Impairment	Deaf/Hard of Hearing	Developmental Disability
Health Impairment	Language Impairment	Learning Disability
Orthopedic Impairment	Psychiatric Disability (anxiety, depression)	Speech Impairment
Other (please specify)

Please describe the disability in more detail

Please describe your learning disability.

Did you have an accommodation letter from SVU during the previous school year?

YesNo

Did your diagnosis or disability change during the previous school year?

YesNo

Please describe how your diagnosis or disability has changed? (please attach additional documents regarding the changes at the end of this survey).

Do you need to adjust your accommodations from the previous school year?

YesNo

Please list any changes you need to make to you accommodations. (Please note, changes in accommodations may require additional documentation and interviews. Please attach it at the end of this survey and our office will contact you regarding a time to meet to discuss the changes).

The above conditions/conditions are:

Permanent/ChronicTemporary

Based on your disability, select the accommodations you believe you will need in college in order to have equal access. Accommodation approval is based upon supporting documentation of a disability.

Environment Needs

Accessible SiteAdjustable TablePreferential SeatingSpace for a WheelchairSpecial Seat

Equipment Needs

CCTVClosed CaptioningListening DevicesLow Vision Aids

Testing Needs

Alternate FormatCalculatorComputer/iPadDistraction Reduced SiteExtended TimeReaderSpell CheckerWriter/Scribe

Support Needs

ReaderLab AssistantNote Taking AssistanceWriter/Scribe

Instructional Needs

BrailleLarge PrintTextbooks in Alternate FormatSpelling AccommodationsAudio Record LecturesDisability Related Absences

Other: (Please Specify)

Housing/Dining:

Room Accommodation (If Needed)

Dining Accommodation (If Needed)

Accessibility Services must receive this form and appropriate documentation of your disability to support requested accommodations prior to consideration and provision of accommodation. Forms and documentation can be uploaded at the end of this survey or sent to accessibility@svu.edu. Accessibility Services reserves the right to request additional documentation should the need arise during the review process. After the review process is completed, the applicant must meet with Accessibility Services to discuss accommodations, procedures, and policies.

Please note that Accessibility Services may exchange information with other relevant authorities on campus to evaluate and facilitate the provision of accommodations. Information regarding disability is kept by Accessibility Services and is considered an academic record but is not noted in any way on the student’s transcript. Please note disability related information will be shared with local and state agencies as required by the law. In signing this form, you are signifying your knowledge of and agreement with this practice.

Please type your full name below to sign you agree.

I am the:

StudentParent/Guardian

Parent Full Name:

Parent Phone Number:

1. Please upload any documentation to support your accommodation needs.

2. Please upload any documentation to support your accommodation needs.

3. Please upload any documentation to support your accommodation needs.

reCAPTCHA helps prevent automated form spam.

The submit button will be disabled until you complete the CAPTCHA.