Accommodation Request Form

Questions

1. What is your major?
2.  

   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
3. What is your diagnosis/ disability? How and when was your disability diagnosed? * (Required)
4. Please describe how your disability impacts you on a daily basis (learning, sleeping, eating, breathing, caring for self, mobility, sensory etc.) * (Required)
5. Please describe how your disability might impact you in an academic setting (classroom, testing, studying/ reading, writing, physically etc.). * (Required)
6. Please identify any medications you are taking that have side effects. * (Required)
7. Please describe services / accommodations you received in high school, standardized testing or other colleges.
8. What specific accommodations are you seeking at Clark State? * (Required)
9. List any other solutions that might help you now, or that have helped in the past. * (Required)
10.  

    How would you like to meet? * (Selection is Required)

    Virtually

    In-person: Springfield

    In-person: Beavercreek

    Additional Note or Comment
11. Please provide a personal email address if you'd like to receive copied communications. Type "None" if you'd like to opt out.
12.  

    Do we have permission to text the provided phone number(s)? * (Selection is Required)

    Yes

    No

    Additional Note or Comment
13. 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.