Request For ADA Accomodations | Survey Builder

Below is a student request for ADA Accommodations.

Thank you for your consideration.

NYS Course Number

End of Course Date

Personal Information

Full Name

Email

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

CIC/Instructor Information

Name

Email

Accommodations Requested (Check All That Apply)

Extended Time

Separate Room

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 requirements