UC Blue Ash Online Application for Accessibility Services

UC Blue Ash Online Application for Accessibility Services
Student's Full Name: *

First Name Last Name
UC Student Username: *
bearcabac
UC Email: *
Only UC email accounts can be used by Accessibility Resources to communicate with UC students.
Student ID (M-Number) *
M########. Can also be found on your student ID.
Phone Number: *

Area Code Phone Number
Date of Birth: *

Month Day Year
Home College: Select the College of your primary major *
Intended Major:
Current student status: *

Incoming Student (Freshman or Transfer Student starting Fall 2020) Returning Student
What semester are you requesting academic accommodations start in? (If you're an incoming Freshman starting in Fall 2020, please select Fall 2020) *

Fall 2020 Spring 2021 Summer 2021
Are you a Distance Learner? (Example: All of your courses are online) *

Yes No
Are you seeking permanent or temporary accommodations? (Temporary accommodations would be for injuries, surgeries, temporary conditions etc.) *

Temporary Permanent
For what disability are you seeking accommodations? *
How does your disability impact you in the academic setting? *
Examples: test-taking, class attendance, taking notes, understanding materials, speaking, comprehension, etc.
During your intake interview, will you require any accommodations? Please list any accommodations you would like to request. *
List and describe (if applicable) any other areas of University Life that might be impacted by the disability (housing, transportation, building accessibility, parking, etc.) *
Are you transferring from a University of Cincinnati branch campus? *

No Yes, UC Clermont Yes, UC Clifton
If yes, did you receive accommodations at that campus?

Yes No
Did you receive special education services or accommodations in K-12 or at another post-secondary education institution? If so, check all that apply: *

None 50% Extended Time on Testing 100% Extended Time on Testing Distraction Reduced Testing Environment (small group) Individual Testing Room Reader Scribe Use of a Computer (during class or testing) Enlarged Font FM System ASL Interpreter Captioning Communication Access Realtime Translation (CART) Accessible Furniture Excused Medical Absences Extended Time on Assignments Alternative Format Textbooks Tape Recorder Notetaker Assistive Technology
If deemed eligible for services, what accommodation(s) are you requesting from Accessibility Resources? *

None 50% Extended Time on Testing 100% Extended Time on Testing Distraction Reduced Testing Environment (small group) Individual Testing Room Reader Scribe Use of a Computer (during class or testing) Enlarged Font FM System ASL Interpreter Captioning Communication Access Realtime Translation (CART) Accessible Furniture Excused Medical Absences Extended Time on Assignments Alternative Format Textbooks Tape Recorder Notetaker Assistive Technology
Are you working with any external support networks or organizations? (Example: Vocational Rehabilitation Services, Veterans Services, etc.). If so, what services or assistance are they providing? *
Have you been prescribed medication applicable to your disability? If yes, how does the medication impact your daily function and /or academic work? *
What areas do you excel at and enjoy (academic, social, other) at the University of Cincinnati? Please explain. *
What areas are more challenging for you (academic, social, other)? Please explain. *
Please share any additional information you would like to provide. *
Medical Professional Disability Verification Form or Supporting Disability Documentation

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Please upload your Medical Professional Disability Verfication form or documentation supporting your request for accommodation that meets Accessibility Resource's documentation guidelines. Note: JPEG, PNG, or other image files containing photographs of documentation will not be accepted and may delay review of your documentation. Please provide scanned PDF or digital documents. Cancel of
Additional Documents:

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Upload any additional documentation, assessments, etc. in support of your request for academic accommodations. Cancel of
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