Request for Accommodations Form
Request for Accommodations Form
To request reasonable accommodations, complete this form, attach photocopies of all appropriate documentation described below or have them sent to the College of Nursing Attention to Dean of Students (contact information below), sign and date the attestation. If you have any questions regarding your request, contact the Dean for Students. Phone: 315-448-5040 Fax: 315-448-5745 Email: terry.pudney@sjhcon.edu Mailing Address: St. Joseph’s College of Nursing Attn: Dean of Students 206 Prospect Ave. Syracuse, NY 13203
Name
Name
*
First
Last
Phone
Phone
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Email
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Program Option
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Program Option
Weekday Associate Degree
Weekday Dual Degree Partnership in Nursing
Evening/Weekend Associate Degree
Evening/Weekend Accelerated Dual Degree Partnership in Nursing
Anticipated Graduation Year
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Anticipated Graduation Year
December 2020
May 2021
December 2021
May 2022
December 2022
May 2023
December 2023
Previous accommodation were granted in (check all that apply)
Previous accommodation were granted in (check all that apply)
High School
College
Professional Program
N/A
Other
Accommodations that you are currently requesting (check all that apply):
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Accommodations that you are currently requesting (check all that apply):
Addiional Time
Seperate/Alternative Testing Location
Private Testing Location
Reader
Other
Other
DIRECTIONS: Please list any individual(s) whom you wish to be informed of your need for reasonable academic accommodations. Please complete this form as early as possible since some accommodations require early
planning. We cannot guarantee that accommodations can be implemented in time without enough notice.
*
DIRECTIONS: Please list any individual(s) whom you wish to be informed of your need for reasonable academic accommodations. Please complete this form as early as possible since some accommodations require early
planning. We cannot guarantee that accommodations can be implemented in time without enough notice.
Level I Course Leaders
Level 2 Course Leaders
Academic Advisor
Other
Other
Directions for documentation:
Candidates requesting reasonable accommodations because of disabilities covered by applicable laws must provide photocopies of documentation according to these standards: 1. The documentation must be an evaluation and/or diagnosis by a licensed professional. The diagnosis must be within the professional's scope of practice. If testing was performed on the candidate, the results of those tests must be provided. 2. The documentation must be signed by the licensed professional on official letterhead from that person's practice. The professional must be clearly identified by name and profession. 3. The documentation must be from within the last three (3) years. 4. The documentation must state the diagnosis clearly and must specify what accommodations are required for the candidate to experience a fair educational experience. The accommodations must be presented as a requirement given the nature of the disability, not as a suggestion. 5. Documentation from a school psychologist is only acceptable if the candidate is still a student in that school system. IEPs and 504 plans from a candidate's secondary education or earlier are not acceptable because they are administrative documents, not the evaluations of licensed professionals, and they are not assessments of the candidate as an adult.
My Documentation (Select all that apply)
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My Documentation (Select all that apply)
Already on file
Attached
Being Mailed
Being Faxed
Other
Other
Upload a File
Attach Files
Upload a File
Attach Files
Upload a File
Attach Files
In addition to submitting this request, please note that it is your responsibility to meet with your faculty members and directly inform them that you will need academic accommodations in their course. In many instances, it will be most helpful for you to discuss your needs in more detail with individual faculty members. It is your decision alone whether or not to disclose to your instructors the specific nature of your disability (dyslexia, epilepsy, ADD, etc.). It is recommended that you advocate for yourself early in the semester/term, giving faculty time to make necessary changes in their course preparation, delivery or testing plans. This also helps faculty more clearly understand how they can best assist you. In addition, you can schedule an appointment with the Dean of Students to discuss your accommodations, and your Academic Advisor(s) may be an additional source of support as well. PLEASE READ AND SIGN: I declare and affirm that the statements made in this request, including accompanying documents, are true, complete, and correct and I understand that my request for accommodations will be based on a documented disability and the supporting documentation currently on file. Upon my request for notification, faculty, advisors, and staff will be notified only of the specific academic accommodations that should be granted (extended time, alternate test location, text to speech technology, etc.). The specific nature of my disability and the actual evaluation data will not be released unless specifically requested by me. This authorization for accommodation only applies to the current academic semester/term. This form must be completed each semester/term since faculty names and classes will change. Once all documentation is provided, you will review the accommodations with the Dean of Students prior to them being sent to any faculty members.
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Date
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Questions, Comments, or Concerns