Request for Access Accommodations

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

ex. C01234567

Email

Please use your university issued email address

Phone Number

(###) ###-###

Date of Birth

What semester do you anticipate starting classes?

Specific Accommodation Information

My diagnosed disability falls into the following category (mark all that apply).

Specific Diagnosis

Are you currently being treated for your disability?

What outside supports do you have for your disability?

medication, vocational rehab, counseling, equipment, or software

What is the impact of your disability when you're in the academic setting?

Testing, lecture, accessing faculty, reading, writing, computer access

Are there limitations/impediments to learning/functioning you may struggle with in the Ivy Tech academic setting?

For example, family commitments, work commitments, transportation, etc.

What strategies do you use to retain classroom information? How do you study and prepare for class?

What accommodations have you used previously for testing?

What accommodations have you used previously for classwork?

What accommodations have you used previously for campus access/mobility?

What accommodations are you requesting currently?

Do you have any additional concerns that have not been addressed on this form?

Documentation Guidelines

Choose the link below to review Disability Support Services Documentation Guidelines.
https://www.ivytech.edu/dss/

Upload supporting document(s)

Release of Information

You may authorize the Office of Disability Support Services (DSS) to communicate with the following individuals, agencies, or service providers regarding your access accommodations and services. This release will remain in effect until you rescind the authorization.

Ivy Tech faculty and staff such as Advisor, Financial Aid, Registrar, Test Center, etc.

External Constituents such as diagnosing or treating physician or school that previously provided services

Source of Documentation such as treating or diagnosing physician or school that previously provided services

Family, guardian, personal assistant, or other

Name, relationship, phone number

Request for Access Accommodations

Student Information

Specific Accommodation Information

Release of Information

Document Information