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Reasonable Accommodations Request
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New Reasonable Accommodations Request
Existing Reasonable Accommodations Notification
This pathway is to be utilized if you are requesting accommodations that have not been previously granted in a determination letter from the NYS Department of Health or your current course starts after the expiration date noted in your determination letter.
NYS Course Number
You can get this from your instructor.
NYS Provider Number
You can get this from your instructor.
End of Course Date
Personal Information
Full Name
Email
Phone
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
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Armed Forces Americas
Armed Forces Pacific
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District of Columbia
Federate States of Micronesia
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Maine
Marshall Islands
Maryland
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Michigan
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Mississippi
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New Hampshire
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North Carolina
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Northern Mariana Islands
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Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
CIC/Instructor Information
Name
Email
Accommodations Requested (Check All That Apply)
Extended Time
Separate Room
Reader
Breaks During Testing
Other…
Enter other…
Student:
You MUST provide any documentation from professionals who have conducted assessments, or who have rendered diagnoses to support the accommodation request. This can be in the form of an Individualized Education Program (IEP), and/or a formal psycho-educational evaluation.
IEP Attachment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
The pathway is be utilized if you have a determination letter previously granting reasonable accommodations from the NYS Department of Health
and
your current course start date falls on or before the expiration date specified in the determination letter.
NYS Course Number
You can get this from your instructor.
NYS Provider Number
You can get this from your instructor.
End of Course Date
Personal Information
Full Name
Email
Phone
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
CIC/Instructor Information
Name
Email
Accommodations Requested (Check All That Apply)
Extended Time
Separate Room
Reader
Breaks During Testing
Other…
Enter other…
Must match previously determined accommodations in determination letter.
NYS Department of Health Reasonable Accommodation Letter
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Determination Letter Expiration Date
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