ADA Checklist
Name ____________________________________________________ Student ID _______________________________
Address ___________________________________________________________________________________________
Telephone(s) _______________________________________________________________________________________
Email Address _________________________________________________________________________@haywood.edu
Major ____________________________________________________ Advisor _________________________________
_____ Form 1 - Procedures for Requesting Accommodations at HCC
_____ Form 2 – Voluntary Self-Disclosure of Disability
_____ Form 3 – Accommodation Form for ACCUPLACER
_____ Form 4 – Accommodation Form for Classroom
_____ Form 5 – ADA Checklist
_____ Form 6 – Success Plan
_____ Form 7 – Addendum
_____ Form 8 – Safety Plan for Individuals with Disabilities
_____ Form 9 - Documentation from medical service provider
_____ Form 10 – Equipment Agreement
_____ Form 11 – Software Agreement
_____ Form 12 – Sign Language Interpreter Service Agreement
_____ Form 13 ___ - Recommendations for Success
_____ I understand that it is my responsibility to inform each of my instructors of my disability, to request
accommodations, and to request academic assistance during instructor office hours and/or in the LSS.
_____ I understand that HCC faculty and staff will adhere to confidentiality and not disclose my disability without written
consent.
_____ I understand that prior to or at the beginning of each semester I must review my Accommodations Plan with the
counselor.
__________________________________________________________________________________________
Student Signature
Counselor Signature
Date
__________________________________________________________________________________________
Parent Signature if student is under 18 years of age
ADA Form 5 * Effective January 1, 2013 * Revised 11.12.2014
Date