Office of Accommodations and Disability Services APPLICATION … · 2019. 9. 13. · Office of...
Transcript of Office of Accommodations and Disability Services APPLICATION … · 2019. 9. 13. · Office of...
Office of Accommodations and Disability Services APPLICATION FOR ACCOMMODATIONS
Bring this application and supporting documentation to your appointment.Middletown 540-869-0758 Fauquier 540-351-1517
Name: _____________________________________ Student ID Number: _____________
Address: ___________________________________ Telephone: (Day) _______________
___________________________________________ Telephone: (Cell) _______________
City State Zip
LFCC E-mail Address_________________________ Date of Birth _________________
When will the accommodations need to start? Fall Spring Summer Year: 20____
How did you learn about our services?
Access Syllabus Statement Adult Rehabilitation Agency Another Student College Instructor College Staff High School Staff Parent Orientation Website Other _____________________________________________________________________________________
Disability: Please check all that apply
Acquired Brain Injury Psychological/ Mental Health/Emotional ADD/ADHD Deaf/Hard of Hearing Speech Impairment Learning Disability Blind/Visual Impairment Mobility/Orthopedic Impairment Health Impairment Development Disability Language Impairment Other _____________________________________________________________________________________
Is the above condition: Permanent/Chronic/Unknown Temporary Note: If your medical condition is not permanent in nature, the college is not required by law to provide any accommodation, but ODS may be able to assist you on a temporary basis.
Educational History As far as you can recall, if you’ve had past difficulties in school and/or work, please describe your academic concerns: ____________________________________________________________________________________________
____________________________________________________________________________________________
If you are registered with Virginia Rehabilitative services, please check all appropriate boxes and complete a consent form to allow exchange of information between Disability Services and Rehabilitative Services.
Registered with Department of Rehabilitative Services Registered with Department for the Deaf and Hard of Hearing Registered with Department for the Blind and Visually Impaired
Accommodations
Based on your condition or disability, check any specific accommodations below you would like to apply for. (Accommodation
approval is based on supporting documentation and conversation with a counselor.)
Absence
Accessible site
Adjustable table
Alternate format test
Audio record lectures
Calculator
Closed Captioning
Computer
Distraction reduced site
Extended time
Interpreter
Large print
No scantron
Note Taker
Preferential seating
Reader
Space for wheelchair
Special seat
Spelling accommodation
Textbooks in alternate format
Other: _______________________________________________________________________________
*LFCC will not provide personal assistants, devices, and/or equipment. Our office will assist in making arrangements for these
accommodations when needed and requested.
Documentation
In order to be eligible for accommodations, you must provide the Office of Accommodations and Disability Services
documentation of your disability or condition that requires accommodation.
Criteria for documentation
1. A diagnostic statement identifying the disability and date of the most current diagnostic evaluation. A description of
the diagnostic tests, methods, and/or criteria used, which should follow adult norms.
2. A description of the current functional impact of the disability. There should be a description of how the individual’s
identified impairment substantially limits a major life activity. The description should include the current functional
impact on physical (including mobility and dexterity), cognitive (including processing, attention, and
communication), and behavioral abilities and should be described through specific results from the diagnostic
procedures.
3. A statement indicating treatments, medications, and assistive devices / services in use including a history of previous
academic adjustments and auxiliary aids and services and their impact. Recommendations regarding
accommodations should be reasonable within the academic setting.
4. The credentials of the professional(s), if not clear from the letterhead or other forms. Diagnosing professionals shall
not be family members or others with a close personal relationship with the individual.
5. Documentation should be current, occurring within the last three (3) years.
6. IEPs may not be sufficient documentation to support the need for academic accommodations. Please review your
IEP with disability services personnel to identify if additional documentation is required.
Additional supporting documentation beyond what is described above may be helpful, for example, copies of IEPs, 504 plans,
previous accommodations at another college, university, or job site, etc.
The Office of Accommodations and Disability Services must receive this form and appropriate documentation prior to
consideration and provision or approval of accommodations. Once documentation is received, it is the student’s
responsibility to schedule an appointment with the counselor on their campus to discuss accommodations, procedures, and
policies. Information contained within the file will be kept confidential and will not be shared with anyone outside of LFCC
without your express authorization. The college requests appropriate documentation of disability be submitted 30 days prior
to receiving approved accommodations.
The Office of Accommodations and Disability Services will exchange information with other relevant authorities on campus to
evaluate and facility the provision of accommodations. By signing this form you acknowledge and agree with this process.
Student signature: _____________________________________ Date: _________________________