The University of Northern Iowa, in compliance with the Americans with Disabilities Act (ADA), will provide
window air-conditioners or single/special room assignments as a reasonable accommodation in select residence
hall rooms of students with documented disabilities.
A residence hall is more than just a place to sleep and study. It is a place to relax, socialize, and partake in
educational and recreational activities. Because this is a shared facility by hundreds of students participating in
various residence hall activities throughout the day, living in a single room does not necessarily provide a
student with a quiet, distraction-free environment.
Air conditioners may be installed in select residence halls for those with chronic health conditions. Typically,
allergies are not considered disabling; however, all accommodations are determined on a case-by-case basis.
The dining services will have a registered dietician and/or staff member meet with students who require a
special dietary modification based on a documented disability. Reasonable accommodations will include
dietary instruction and/or special dietary meals being produced for the student.
Please note that administration of services will not occur until a completed Request for Services form and
relevant documentation are on file at Student Disability Services (SDS).
PLEASE SEND THIS COMPLETED FORM AND DOCUMENTATION TO:
Student Disability Services
103 Student Health Center
University of Northern Iowa
Cedar Falls, IA 50614-0385
OR BY FAX TO:
319-273-7576
_________________________________________________________________________________________
I. GENERAL INFORMATION
Name: __________________________________________UNI Student ID Number: _____________________
Gender: _________________________________
Date of Birth: _____________________________
Current Mailing Address: ____________________________________________________________________
City: _________________________________State: ______________________Zip Code: _______________
Local Phone Number: ______________________________ Cell Phone Number: ________________________
Preferred E-mail Address: ___________________________________________________________________
If approved, when would this accommodation begin? _____________________________________________
CONTINUED
II. UNIVERSITY OF NORTHERN IOWA STATUS
Current UNI Student:
 Freshman
 Sophomore
 Junior
 Senior
 Graduate Student
 Other (please explain): ______________________________________________________________
Major: _____________________________________________________
Minor: _____________________________________________________
Prospective UNI Student:
 Not yet admitted to UNI (transfer/prospective incoming freshman/prospective graduate student)
 Prospective transfer student (admitted)
 Prospective incoming freshman student (admitted)
 Prospective graduate student (admitted)
 Other prospective student (please explain): ______________________________________________
Anticipated Entrance Date:
Semester (Spring, Fall, Summer): _______________________________ Year: ______________________
Anticipated Major: _____________________________________________________________________
III. RESIDENCE LIFE/DINING IMPLICATIONS
Please describe in your own words your disability, including diagnosis as well as cause and date of onset, and
how it affects you in general.
How does your disability affect your living in the residence halls and/or dining in the residential dining
facilities?
What accommodation(s) are you requesting for your disability?
IV. STUDENT VERIFICATION
I verify that the information contained within this document is accurate to the best of my knowledge. I
understand that utilizing certain accommodations may require me to relocate to another residence hall and that
my documentation may be shared with appropriate Department of Residence staff in order to develop an
appropriate accommodation plan.
Student Signature: ______________________________________________Date: ____________________
Chapter 22 Code of Iowa: This information is requested to determine your eligibility for accommodations. Only directory
information may be released to third parties. All items are required and therefore incomplete forms may not be processed.
04/2014