Student Intake Form
STUDENT ACCESSIBILITY AND ACCOMMODATION
T: 253.879.3395 or 3399, F: 253.879.3786 Email: saa@pugetsound.edu
Date: ________ Preferred Name: ____________________________________ ID#: ___________
Home State:____ DOB: _________Tel: __________________E-Mail:________________________
(Optional): Gender ______________________________ Pronoun _____________________
Circle One: Freshman / Sophomore / Junior / Senior / Graduate/Transfer(at what level)________
Please describe your disability ___________________________________________________
______________________________________________________________________________
Please list the specific reasonable accommodations you are requesting ________________
_____________________________________________________________________________
Do you have any other medical problems? __________________________________________
Please list medication __________________________________________________________
I understand that:
 It is my responsibility to retain copies of all documentation that I submit to SAA. SAA will not
forward or supply students with copies of any documents submitted.
 I can request a Letter of Verification listing accommodations used while attending UPS
 Registration with SAA is not part of my official academic record. It will not be on my transcript.
 Registration with SAA is not complete until I have completed an intake interview to discuss my
reasonable accommodation needs.
 Academic accommodations must be formally requested each semester, by meeting with each
instructor to discuss accommodations, and returning a signed copy of the decision letter to SAA.
 If I need assistance with SAA procedures, I will stop by the SAA office during office hours.
 I will schedule a meeting with the SAA Director if I have any concerns.
Student Signature: _______________________________________ Date: ______________
SAA OFFICE INFO (DO NOT WRITE BELOW THIS LINE)
Documentation on file: YES______ Requested ________ Received ________
Diagnosis: ___________________ Approved Accommodations: __________________
__________________________________________________________________________
Note Information:____________________________________________________________
___________________________________________________________________________
Revised 8/12/2015