a b c d e f g h i j k l m n
o p q r s t u v w x y z

Disability Resource Center

Missouri State > The Disability Resource Center > Request for Accommodation

Request for Accommodation

Form Completion Date

Request Term

First and Last Name

M#: ex. M12345678

Address

City, State, Zip: ex. Springfield, MO 65897

Home Phone: ex. 417-555-1234

Cell Phone: ex. 417-555-1234

Email Address: ex. name@missouristate.edu

Academic Status

Major

Would you like to register to vote?

Type of Disability (check all that apply)

Blind/Low Vision
Deaf/Hard of Hearing
Deaf/Blind
Health Related
Orthopedic
Learning Disability
ADD/ADHD
Psychological
Acquired Brain Injury
Chemical Dependence
Other (please explain below)

If you selected OTHER in the "Type of Disability" section, please explain here.: 1000 characters remaining.

Type of Accommodations Requested (check all that apply)

Learning Environment: Priority Registration
Learning Environment: Braille
Learning Environment: Large Print
Learning Environment: Alternative Textbooks
Learning Environment: Disability Related Absence
Learning Environment: Video Captioning/Transcription
Learning Environment: Preferential Seating
Learning Environment: Accessible Site
Learning Environment: Adjustable Tables
Learning Environment: Space for Wheelchair
Learning Environment: Sign Language Interpreter
Learning Environment: CART/Transcription
Learning Environment: Notetaker
Learning Environment: Lab Assistant
Learning Environment: Service Animal*
Learning Environment: Personal Care Attendant*
Testing: Extended Time
Testing: Out-of-Class
Testing: Distraction Reduced Area
Testing: No Scan-Tron
Testing: Reader
Testing: Scribe
Testing: Alternative Format
Testing: Calculator*
Equipment: Assistive Listening Device
Equipment: Assistive Technology
Equipment: Low Vision Aids*
Equipment: Calculator*
Equipment: Tape Recorder*
Residence Hall: Handrails
Residence Hall: Roll-in Shower
Residence Hall: Bathtub w/ Shower
Residence Hall: Flashing Doorbell/Alarm
Residence Hall: Service Animal*
Other (please explain below)

* not provided by the University

If you selected OTHER in the "Type of Accommodations Requested" section, please explain here.: 1000 characters remaining.

By entering your name in the box provided, you agree that all information presented on this form is accurate

SHOULD A REQUEST FOR ACCOMMODATION BE DENIED BY THE DISABILITY RESOURCE CENTER, THE STUDENT WILL RECEIVE A WRITTEN STATMENT OF JUSTIFICATION FROM THE DIRECTOR AND INSTRUCTIONS REGARDING THE APPEAL PROCESS.

Human Verification

Last Modified: April 27, 2012

Disclaimer
Accessibility
EO/AA

© 2010 Board of Governors, Missouri State University

Maintained by: Disability Resource Center

Contact Information