Accommodation Request Form
disAbility Resource Office
Name (required):
Class Year (required):
Contact Phone Number (required):
Anticipated Graduation Date (required):
Faculty Adviser (required):
Disability Background
Do you have a diagnosis or diagnoses?
Unsure
No
Yes
If No or Unsure would you like to learn more about medical or mental health providers who
could assist in diagnosis or providing treatment?
No
Yes
If Yes, when were you diagnosed and by whom? _______________________________________
______________________________________________________________________________
Are you seeking a temporary accommodation as the result of an injury or temporary illness?
Yes
No
In your own words, please describe your disability/disabilities and how it affects your ability to function
on or to fully access the Grinnell College campus_____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List any medications you are currently taking and their side effects that may affect your performance as
a student_____________________________________________________________________________
_____________________________________________________________________________________
Accommodation History
What accommodations or assistive technology have you previously used in an educational, social,
residential, or dining setting?_____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Functional Impacts
Task
Attention/Concentration
Taking Notes
Starting, organizing, and
completing tasks
Interacting with others
Following verbal
directions
Following written
directions
Seeing
Hearing
Understanding visual
information
Memorizing information
Understanding auditory
information
Putting thoughts into
writing
Using my hands
Speaking clearly
Sitting for long periods
Moving around
(standing/walking)
Tolerating stress
Motivation
Finishing tests on time
Spelling
Writing
Reading at a standard
rate
Understanding what I
read
Doing math calculations
Doing math word
problems
Managing time
No
Impact
Minimal Moderate Severe
Impact
Impact
Impact
Comments
Task
No
Impact
Minimal Moderate Severe
Impact
Impact
Impact
Comments
Studying
Other (Please list)
Other (Please list)
Other (Please list)
Accommodations
What accommodations would you like to request (see supplement for information about some of the
accommodations that have been used by some students in the past)?____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List any assistive technology you would like to request_________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Information
Do you plan to work on campus during your time at Grinnell College? Yes
Unsure
No
If yes or unsure, would you like to receive information about receive information about work
place accommodations?
Do you anticipate that you will require accommodations to fully participate in any athletic, recreational,
or organization activities while at Grinnell?__________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide any additional information you feel would be useful when considering accommodations
that may be needed at Grinnell College_____________________________________________________
Appendix A
Accommodations that have been used by students at Grinnell College **Note this list is not an
exhaustive list of all accommodations available and not all accommodations are reasonable for all
students**
This is a resource meant to help you and/or your provider think critically about what accommodations
might be important for you to utilize during your time at Grinnell College.
Please check those accommodations you will need in the Grinnell College setting (Accommodations are
approved based on supporting documentation)
Instruction Accommodations
□ Braille
□ Large Print
□ Electronic Textbooks
□ Disability Related Absence
□ Use of Computer
□ Captioned Videos
Testing Accommodations
□ Extended time
□ Reduced Distraction Environment
□ Reader/Writer
□ Alternative Format
Assistive Technology
□ Smart Pen/Recorder
□ Voice to Text Software
□ Text to Audio Software
Residential Accommodations
□ Pre-placement
□ Assistance Animal*
□ Air-conditioning
□ Substance Free Housing
Dining Accommodations
□ Ingredient Lists
□ Small portion frequent meals
Support Persons
□ Interpreter
□ Notetaker
□ Reader
□ Writer
□ Lab Assistant
□ Service Animal*
□ Personal Care Assistant*
Environmental Accommodations
□ Preferential Seating
□ Physically Accessible Room
□ Hearing Loop
□ Technology Adapted Room
□ Adjustable Table
□ Space for Wheelchair
□ Additional Seat for Attendant