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Request for Accommodations Form

All requests must be reasonable and supported by appropriate documentation.

Semester/Student Information

First Name Last Name

Student ID

Student Phone

Student Email (Use VSU email account)

Term Select a term Summer Fall Spring

Individual Course Information

Complete the following information and check the appropriate box next to the accommodations you are requesting.  You will complete a separate section for EACH CLASS.  Fill in additional information (e.g. percent extended time, class locations) as indicated. 

Please note, if you are requesting materials in alternate format, an Alternate Media Request Form (available in Word format on the Access Office forms page) must be completed and submitted seperately.

Course #1:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #2:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #3:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #4:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #5:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #6:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Continue adding courses below or click here to skip to the bottom to sign and submit.

Course #7:

Title Please use course abbreviation (ex: MATH 1101, NOT "Math Modeling")

Instructor

Extended Testing Time

Reduced distraction testing environment

Use of a word processor

Assistance of a reader

Assistance of a scribe

Use of a hand-held spell checker

Use of a dictionary

Copies of overheads/PowerPoint slides

Adaptive Table/Chair      Class location (Include building and room number)

Copies of peer notes

Permission to tape record lectures

Preferential seating

Text materials in alternate format

Other (please describe):

Electronic Signature

I understand that students must pick up their accommodation letters from the Access Office, deliver them to their professors for signing, and return them to the Access Office for accommodation implementation. Checking the box below serves as an electronic signature.

I agree