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Request for Accommodation Plan

Robin Tardiff

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Request for Accommodation Plan

REQUEST FOR ACCOMMODATION PLAN

Student Name:  

Date:

Program Enrolled In:

 
Campus Attended: Bangor: 
Wilton:
 
How do you attend classes? On campus:
Online:
Hybrid:
Have you spoken to your current Instructors about this request? Yes:
No:
 
Have you spoken to your Program Director about this request? Yes:
No:
 
Have you utilized accommodations in prior education? Yes:
No:
 

List Current Courses Enrolled in with Current Grade:

Course ID/Name Online On Campus Current Grade

Students Cumulative GPA:

COMPLETED BY STUDENT

Is your documentation from a professional qualified to address your disability? Yes: 
 No:
Does your documentation state a specific diagnosis? Yes:
No:
Does your documentation state functional limitations (if any) within the academic environment as a result of the disability? Yes:
No:
Does your documentation state the degree to which the identified disability limits the student in comparison to most people? Yes:
No:
Does your documentation have the testing or evaluation procedures that were utilized to assess the level of limitation, and is within the last three years? Yes:
No:
Does your documentation have a report of the specific test or evaluation results and is within the last three years? Yes:
No:
Does your documentation state recommendations for academic accommodation? Yes:
No:

State the specific accommodation request(s) and attach all required supporting documentation to support the request for accommodation. See pages 6-8 in the Accommodation Services Handbook for documentation requirements and requirements for specific disabilities.

My signature acknowledges my receipt of Beal University's Accommodation Services Handbook and that I agree to the terms set forth.

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Request for Accommodation Plan

Robin Tardiff

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