Accessibility Services Request

Request for Academic Accommodations
Student Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Student ID Number
Phone Number
Please enter a valid phone number.
Email
example@example.com
Academic Information
Academic Level
Major/Program of Study
At what location do/will you attend classes? (Check all that apply)

On CampusMayfair CampusOnline
Anticipated Semester of Graduation/Program Completion
Are you a transfer student?

YesNo
Where did you attend previously?
Disability-Related Information
What is your diagnosed disability? (One or more)
When and how did you receive your diagnosis/diagnoses?
What are the characteristics of your disability? How does your disability impact you?
Describe any ways your disability/disabilities impact you in the following areas. If an area is not relevant to your situtaion, respond with N/A.
Cognition & Academics (reading, writing, listening, notetaking, etc.)
Executive Functioning (organization, time management, memory, managing distractions, etc.)
Emotional/Self-Regulation (managing stress/anxiety, frustration tolerance, etc.)
Physical (walking, speaking, hearing, seeing, etc.)
What would you identify as your strengths?
What are strategies you use to be successful?
What accommodations, modifications, or tutorial services have you used in the past?
In what ways were these helpful or not helpful to you?
What accommodation(s) are you requesting at Briar Cliff University?
Do you anticipate these accommodation(s) will be needed only on a temporary (short-term) basis?
Is there any other information you would like to share regarding your request for accessibility services?
Documentation of Disability

Documentation of your disability is required and needs to be submitted to Accessibility Services. It is your responsibility to provide this documentation. Documentation should include the diagnosed disability/disabilities and the severity and impact of the disability on functioning. It is also helpful to include current and/or past accommodations and any recommended accommodations that align with the individual's manifestation of the disability. Documentation needs to be recent (within the last two years) and provided by a qualified professional on professional letterhead. Common sources of information include medical and mental health care providers, psychologists, and reports from a previous school, such as an IEP or multidisciplinary team report.
How will you provide documentation of disability?

I am attaching documentation to this form.I will email the documentation to accessibility@briarcliff.edu as soon as I receive it.I will deliver a hard copy of the documentation to the Coordinator of Accessibility Services.My provider will send the documentation to the Coordinator of Accessibility Services.
Please upload documentation of disability.

Cancelof
Confidentiality and Verification

The information shared with BCU's Accessibility Services is confidential and will be shared with others at the University on a "need-to-know" basis only. This may include instructors, academic advisors, or any other personnel necessary for implementing accommodations if you are approved for them. Information shared by Accessibility Services will be limited to details about academic needs and accommodation(s) only, and personal information (i.e., diagnosis, testing information, etc.) will not be discussed except in unique circumstances or when this information is necessary in providing the accommodation(s). Information and documentation will be kept confidential as described above and in compliance with federal and state laws.

By signing below, I verify that the information I have provided is true and accurate. I also verify that I have read and understand the confidentiality statement above.
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Request for Academic Accommodations

Student Information

Academic Information

Disability-Related Information

Describe any ways your disability/disabilities impact you in the following areas. If an area is not relevant to your situtaion, respond with N/A.

Documentation of Disability

Confidentiality and Verification