Accommodation Request Form

What is your major? * (Required)

 

For what areas do you plan to utilize accommodations? * (Selection is Required)

Classroom and/or Testing Accommodations

Accommodations for Physical Simulations

Clinical/Practicum Accommodations

Additional Note or Comment

What is your diagnosis/ disability? How and when was your disability diagnosed? * (Required)

Please describe how your disability impacts you. Please consider how it might impact you in an academic setting (classroom, testing, studying/ reading, physically etc)? * (Required)

Please identify any medications you are taking and how they impact you. * (Required)

Please describe services / accommodations you received in high school, standardized testing or other colleges. * (Required)

What specific accommodations are you seeking at Clark State? * (Required)

Please provide any additional information you would like to share. List any other solutions that might help you now, or that have helped in the past. * (Required)

 

In some cases, we have the ability to expedite the accommodation process without a meeting: * (Selection is Required)

I would like to meet with someone about my accommodations

I would like my request evaluated to determine if I'm eligible for the expedited process. I understand that if additional information is needed before finalizing my accommodations, staff will contact me via Clark State email, personal email or phone/text.

Additional Note or Comment

Please provide a personal email address if you'd like to receive copied communications. Type "None" if you'd like to opt out. * (Required)

By typing my name below, I am acknowledging that I understand that all communication about these services will come through my Clark State email and/or the contact information I provided within one week of submission of this form. OAS Staff will archive my request after 3 contact attempts. I can have my request reactivated by contacting accessibility@clarkstate.edu. * (Required)