Fillable Request for Accommodations Buena Vista University Storm Lake (Buena Vista University)

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Request for Accommodations Buena Vista University Storm Lake (Buena Vista University)

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File type: PDF

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Request for Accommodations
Buena Vista University – Storm Lake Campus
Name: Date:
Date of birth: BV ID #
Documentation of Disability
• The student is responsible for providing documentation from a professional service
provider (such as a physician, psychiatrist, educational psychologist) to the Director of
the Center for Academic Excellence (CAE) This documentation must include the
description of the disability; names and results of tests administered (if appropriate); the
effect of the disability on student’s ability to access University programs, services and
activities; and suggestions for specific accommodations that would provide access to
University programs, services, and activities
• Documentation will be kept in the student’s confidential file.
• The 504 Coordinator and/or the Director of Academic Excellence reserve the right to
obtain clarification of the diagnosis of the disability, limitation, and accommodation
needs, if necessary.
Disability
State diagnosed disability:
Please provide any additional information regarding the characteristics of your disability:
Are you currently taking medication for this or a related disability? Yes No
If yes, please specify type of medication
Are you presently receiving any ongoing medical treatment? Yes No
Please explain:
Educational History
Major:
Advisor’s name:
Planned attendance: full-time (12 or more semester hours)
part-time (less than 12 semester hours)
Status: first-year (less than 30 hours) junior (60-89 hours)
sophomore (30-59) senior (90+ hours)
graduate student
Current GPA Cumulative GPA
Transferred from
Number of semester hours transferred
Accommodation and Service Needs:
Determination of eligibility for accommodations will be made based upon the documentation
provided and discussion with the student. Accommodation for courses may vary depending on
the nature of the course.
What accommodations have you used in the past?
What were the results of these accommodations?
Have you had any accommodation request turned down by BVU or another institution?
Yes No If yes, please explain:
Accommodations you are requesting:
Please list any additional information which may be helpful to your request.
If you need printed materials in an accessible format, what is your preference?
digital format (for use with screen reader or text-to-speech)
large print
Braille
Do you use adaptive equipment such as a telephone device for the deaf (TDD), assistive listening
device, voice synthesizer, communication board, etc.? Yes No
If yes, is the equipment currently available to you? Yes No
Are you a client of State Vocational Rehabilitation: Yes No
If yes, in which county and state?
Voc. Rehab. Counselor’s name:
I certify that the information in this form is correct and complete.
Signature (required) Date:
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Authorization for Release of Information
I hereby authorize the representatives of the 504 Coordinator and/or the Director of the Center
for Academic Excellence (CAE) at Buena Vista University to be permitted to review and obtain
copies of information concerning my health, academic, and assessment records for the purpose
of evaluating eligibility and accommodation requests.
I further authorize these representatives to be permitted to release, discuss, and exchange
disability and accommodation request information with Buena Vista University faculty, staff, or
affiliated rehabilitation agencies in order to provide full coordination of services.
I agree that any person(s) who may furnish information concerning my records or test data or
therapist/counseling notes shall not be held accountable for releasing this information; and I do
hereby release said person(s) from any and all liability for damages of whatever kind which may
at any time result to me, my heirs, and family or associates because of compliance with this
authorization and release of information, or any attempt to comply with it.
I further release Buena Vista University from any and all liability for damage of whatever kind
which may at any time result to me, my heirs, and family or associates because of compliances
with this authorization, or any attempt to comply with it.
I understand that I may revoke this authorization at any time, except to the extent that action has
already been taken in reliance upon it, by giving written notice to the 504 Coordinator and/or the
Director of the CAE.
____________________________________________________________________________
Print student’s name
____________________________________________________________________________
Student’s signature
________________________
Date
The 504 Coordinator and the Director of the CAE do not have permission to communicate with the
following individuals:
_________________________________________________________________________
Print name Title
_________________________________________________________________________
Print name Title
_________________________________________________________________________
Print name Title
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Request for Accommodations Buena Vista University Storm Lake (Buena Vista University)

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Completed 18 August 2020

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