We appreciate your interest in the services offered by Student Disability Services (SDS). It is important that
you, as the student requesting academic accommodation(s), complete this form to the best of your ability and
return this application to SDS along with documentation supporting your need for accommodation(s). Types of
supportive documentation may include, but are not limited to:
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A psycho-educational or neuro-psychological evaluation
Relevant medical records
A letter from a current physician or psychologist
A recent IEP or 504 Plan
A Summary of Performance or Support for Accommodation Request Form
(Iowa Residents) (http://www.uni.edu/sds/SAR.shtml)
For a complete, step-by-step guide to applying for services, please visit:
www.uni.edu/sds/ApplyForServices.shtml
Please note that administration of services will not occur until a completed Request for Services form and
relevant documentation are on file at 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: ___________________________________________________________________
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. ACADEMIC HISTORY
High Schools Attended
Dates of Attendance
Accommodations/Services Used
Colleges/Universities Attended
Dates of Attendance
Accommodations/Services Used
IV. ACADEMIC 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 you academically (i.e., in which areas/tasks do you struggle as a result of your
disability)?
What accommodation(s) are you requesting for your disability?
Do you work with a vocational rehabilitation counselor?
 No
 Yes:
Counselor’s Name: _______________________________________________________________
Address: _______________________________________________________________________
Phone: _________________________________________________________________________
V. STUDENT VERIFICATION
I verify that the information contained within this document is accurate to the best of my knowledge.
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