Request for Access Accommodations

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

Student IDRequired *

ex. C01234567

EmailRequired *

Please use your university issued email address

Phone NumberRequired *

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

Date of Birth

On which campus(es) will you be attending classes?Required *

Anderson
Bloomington
Columbus
Evansville
Fort Wayne
Hamilton County
Indianapolis
Kokomo
Lafayette
Lake County
Lawrenceburg
Madison
Marion
Muncie
Richmond
Sellersburg
South Bend/ Elkhart
Terre Haute
Valparaiso

Specific Accommodation Information

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

ASD Related

Acquired Brain Injury

Attention Deficit/Hyperactivity

COVID-19 Related

Chronic Health

Cognitive or Intellectual

Communication

Hearing

Learning

Mobility

Physical

Psychological, Mental, or Emotional

Temporary

Visual

DiagnosisRequired *

Are you currently being treated for your disability?Required *

Are you currently being treated for your disability? Yes Are you currently being treated for your disability? No

What outside supports do you have for your disability?Required *

medication, vocational rehab, counseling, equipment, or software

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

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?Required *

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?Required *

What accommodations have you used previously for testing?Required *

What accommodations have you used previously for classwork?Required *

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

What accommodations are you requesting currently?Required *

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

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.Required *

Ivy Tech faculty and staff such as Advisor, Financial Aid, Registrar, Test Center, etc. Yes Ivy Tech faculty and staff such as Advisor, Financial Aid, Registrar, Test Center, etc. No

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

External Constituents such as diagnosing or treating physician or school that previously provided services Yes External Constituents such as diagnosing or treating physician or school that previously provided services No

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

Source of Documentation such as treating or diagnosing physician or school that previously provided services Yes Source of Documentation such as treating or diagnosing physician or school that previously provided services No

Family, guardian, personal assistant, or other

Name, relationship, phone number

Request for Access Accommodations

Student Information

Specific Accommodation Information

Release of Information

Document Information