ACCOMMODATION REQUEST FORM

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Disability Services Office
Kutztown University
VOICE: (610) 683.4108
TTY:
(610) 683.4499
FAX:
(610) 683.1520
www.kutztown.edu/DSO
ACCOMMODATION
REQUEST FORM
Kutztown University encourages academically qualified students with disabilities to participate in its educational programs and services.
Federal regulations define a disabled person as anyone with a physical or mental impairment that substantially limits or restricts one or
more major life activities. Major life activities include; walking, seeing, hearing, speaking, breathing, learning, working, performing manual
tasks, and caring for oneself.
If you have a disability you have the option of completing this form and submitting appropriate documentation in order to request
accommodations. Please see the reverse side for specific documentation requirements. NOTE: This information will be kept strictly
confidential and will enable us to consider possible classroom and testing accommodations and to advise you of academic and other available
support services.
PLEASE PRINT
Name
KU ID #
DOB
Home Address ____________________________________________ City ____________________________________ State _____________
Zip __________________ Major ____________________________ KU Email Address
Cell Phone Number
@live.kutztown.edu
Home Phone Number
____
My disability can be categorized as: (Check as many as apply) If disability is temporary, please indicate.
Attention Deficit Disorder/ADHD
Motor impairment (wheelchair)
Autism/Asperger’s
Psychological/Emotional
Hearing Impairment/Deafness
Speech Impairment
Learning Disability
Veteran/Serving in the Military
Motor Impairment (ambulatory)
Visual Impairment/Blindness
Other Specify
(such as diabetes, epilepsy, heart disease, etc.)
I will need accommodations in the following areas:
Adaptive Physical Education
Early Course Selection
ASL Interpreter or Captioning
Note Takers
Assistance with ordering alternate text (PDF/Word versions)
Record Lectures
Assistance with course substitution request process
Testing Accommodations
Extended Time
Distraction Reduced Environment
Reader
Scribe
Campus housing (housing deposit must be submitted prior)
List specific needs for housing.
Other:____________________________________________________
____________________________________________________
University Access – elevators, curb cuts etc.
This form should be filled out by the student and submitted with copies of appropriate documentation needed (see reverse side) via
fax: 610.683.1520, email: [email protected], or mail to: DSO, 215 Stratton Admin. Ctr., Kutztown University, Kutztown, PA 19530.
Signature
Revised 1.4.16
Date
_____________
GUIDELINES FOR DOCUMENTING DISABILITIES
Documentation from a medical/health professional must be presented on 8-1/2 x 11 letterhead, typed and be signed by the professional.
Learning Disability
A current (within the past 5 years) neuropsychological or psycho-educational evaluation, for the diagnosis in a specific learning disability that
provides clear and specific evidence that a learning disability exists. All tests must have been administered within the past 5 years and address the
following domains:
1. Aptitude: a complete intellectual assessment with all subtests and standard scores reported such as the Wechsler Adult Intelligence
Scale (WAIS).
2. Academic achievement: a comprehensive academic achievement battery with standard scores reported. For example, the WoodcockJohnson Psycho-educational Battery-Achievement, Wechsler Individual Achievement Test, or Kaufman Test of Achievement.
3. Information processing: assessment of short-term, long-term, and sequential memory; auditory and visual processing; executive
functioning; and motor ability, such as the Woodcock-Johnson Psycho-educational Battery would provide.
4. Diagnostic summary: including indication of the substantial limitation to learning caused by the learning disability and a rationale for
specific accommodations.
ADD and ADHD
A current evaluation (within the past 3 years) by a psychiatrist, neurologist, licensed psychologist or other qualified medical professional that
includes:
1. A statement of the diagnosis of ADHD or ADD, based on the DSM-V diagnostic criteria.
2. A description of the current substantial limitation to learning, living or working. Include information from the diagnostic interview
and third party input.
3. Clinical instruments and/or procedures used to determine the diagnosis including results from cognitive or achievement measures.
4. Recommendations for prescriptive treatments, environmental management, and reasonable accommodations.
Psychological Disorders
A current psychological evaluation (within the past 6 months) by a psychiatrist, licensed clinical psychologist, licensed clinical social worker,
neurologist, or other professional certified to diagnose psychological disabilities that includes:
1. A description of the current impact of the disability on the individual's level of functioning.
2. A statement of the diagnosis according to the DSM-V and a description of the nature of the disability.
3. Medical information relating to the individual's needs, including the impact of medication on the individual's ability to meet the
demands of the postsecondary environment in learning, living or working.
4. A rationale connecting the disability to the recommended accommodations.
Mobility, Sensory, Health or Medical Impairments
A current evaluation (within the past 6 months) by a physician or other health professional experienced and certified in the diagnosis and
treatment of the specific condition that includes:
1. A clear statement of the disability with a supporting description including any numerical evaluations that may assist in explaining the
individual's functional limitations.
2. Assessment procedures and testing results.
3. Medical and educational information relating to the individual's needs.
4. A Statement of how the disability limits the individual's ability to function in an academic, residential or employment setting.
5. A rationale connecting the disability to recommended accommodations.
Autism Spectrum Disorder
A current evaluation (within the past 5 years) by a licensed psychologist or neuropsychologist, psychiatrist, physician or other health
professional experienced and certified in the diagnosis and treatment of the specific condition that includes:
1. A clear statement of the diagnosis that conforms to diagnostic criteria for Autism according to the DSM-V.
2. A history of and current functional limitations of major life activities including communication or language skills, social interaction,
restricted, repetitive or other patterns of behavior and activities, sensory functioning, and sensitivity to environmental conditions.
3. Results and interpretation of assessment measures.
4. A history of accommodations and services used previously, and recommendations for reasonable accommodations in the learning,
living or working environment.
Traumatic Brain Injury/Head Injury
A current medical or assessment report (within the past 6 months) from a recommended practitioner, including physicians, neurologists,
rehabilitation specialists or other qualified health professionals certified in the diagnosis and treatment of the condition that includes:
1. A clear statement of diagnosis of the head injury or traumatic brain injury.
2. A description of the current impact of the injury on the individual's ability to function in a learning, living or working environment.
Results of assessment measures used to determine the impact of the injury.
3. Current medications and impact of medications on ability to function.
4. Recommendations for reasonable accommodations in an academic, residential or working environment.
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