Accessibility Services Request Form

* indicates a required field

Student Information

This form is to be completed by the STUDENT. If assistance is needed, please contact Accessibility Services staff to help. Fill out the form as completely as possible prior to meeting with Accessibility Services staff.

First Name

Last Name

Student ID

Please use your university issued email address

Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Who referred you

Educational Background

What is highest level of education/grade you have completed

Name of High School

Years attended:

Did you have an IEP or 504 Plan in High School?

Have you ever attended another college/university/technical school?

Specific Accommodation Information

Declared Disability: (check all that apply)

Please specify

Describe your disability and how it affects your performance in the following settings:

Academic Classroom:

Social/Personal/Living:

Mobility around community/campus environment:

Which of the following do you have difficulty doing? (Check all that apply)

{"display_name":"Which of the following do you have difficulty doing? (Check all that apply)","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}

ACCOMMODATION REQUESTS:

List reasonable accommodations that you believe would allow you equal access to educational opportunities at Northern State University.

PRIVACY STATEMENT:

The Office of Student Accessibility Services is committed to ensuring that all information regarding a student registered in the office is maintained as confidential as required or permitted by law. We recognize information/documentation regarding students as CONFIDENTIAL. No confidential information will be released by SAS unless the student provides written permission. We also adhere to FERPA, (Family Educational Rights and Privacy Act) where college students are considered adults and are allowed to determine who will receive information about them. On occasion, it may be necessary to disclose the nature of your disability in order to assist you in potential safety or emergency situations, such as fire drills, building evacuations, or other situations where safety is a concern. Questions about this policy should be directed to SAS.

GRIEVANCE STATEMENT:

Individuals who believe that they have been discriminated against in any education program or activity or employment situation at the University on the basis of having a disability, a record of a disability, being regarded as disabled, or having association or affiliation with a person who has a disability, may file a complaint with the ADA/504 Coordinator, Dean Sean Blackburn, Avera Student Center Room 222, 1-605-626-3007.

Upload supporting document(s)

**Supporting Documentation from licensed professionals and/or psycho-educational testing reports will be required to be held on file with the Office of Student Accessibility Services prior to accommodations being provided. Questions regarding appropriate documentation should be directed to Accessibility Services Staff**

Accessibility Services Request Form

Student Information

Educational Background

Specific Accommodation Information

Describe your disability and how it affects your performance in the following settings:

Document Information