Fillable ACCESSIBILITY ACCOMMODATIONS REQUEST FORM accommodations@thechicagoschool.edu. (The Chicago School)

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ACCESSIBILITY ACCOMMODATIONS REQUEST FORM accommodations@thechicagoschool.edu. (The Chicago School)

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(Continued on Page 2)
ACCESSIBILITY ACCOMMODATIONS REQUEST FORM
If you are requesting ADA Accommodations, please fill out this form completely and as detailed as possible. Once
you have completed the form, please submit it to
accommodations@thechicagoschool.edu.
STUDENT NAME: ________________________________________________________________ STUDENT ID #: ___________________________________
TCSPP E-MAIL: _________________________________ PHONE #: _________________________ CAMPUS: _________________________________
YEAR IN PROGRAM (1
st,
2
nd
, etc.): ____________ DEGREE LEVEL (BA, Masters, Doctoral): _________________ PROGRAM: _________________________
Please answer the following questions as fully as possible (attach additional sheets if necessary):
1. What is your disability/diagnosis?
___________________________________________________________________________________________
2. Please describe how any disability-related limitations may interfere with your studies (classes, navigating campus,
internship, Study Abroad, dissertation, etc.). Do you expect this condition to impact you for the duration of your academic
program?
___________________________________________________________________________________________
3. Please list the accommodations you are requesting.
___________________________________________________________________________________________
4. In addition to this form, you must provide the ADA Liaison team with a recent letter from your treating professional(s)
identifying your diagnosis and supporting any recommended academic accommodations. (Please note, you may also
provide previous approved accommodations letters from any previous school attended. They are helpful in guiding our
understanding of your needs for accommodations. However, please be aware that TCSPP is not obligated to provide
you with accommodations identical to those received at prior institutions. An assessment is made based upon
reasonableness as opposed to your preferred accommodation). On this line, please identify the name and professional
credentials of the treating professional(s) whose letter(s) you have attached to this request form.
___________________________________________________________________________________________
Revised: September 2019
5. Please share any additional information you would like the ADA Liaison team to know about you. Feel free to attach
additional sheets, if needed.
___________________________________________________________________________________________
Please note that if TCSPP grants all or part of your requested accommodations, those accommodations may not be
available at a practicum or internship site. If you are taking a practicum or internship course, we encourage you to note that
information on this request form and to contact your ADA Liaison and Director of Clinical Training to discuss options.
By submitting this Accommodations Request Form along with documentation from a treating professional, I understand that
the ADA Liaison team will contact me within five business days to review my request. I understand that ADA
accommodations are an interactive process that may require additional information from me or from my treating
professional. To discuss my request, the ADA coordinator may need to meet with me via phone, GoToMeeting, email or in-
person (if on-campus). I also understand that accommodations are not retroactive and do not begin until this process has
been completed and I have been given a Confirmation of Accommodations letter that I will share with my faculty.
STUDENT SIGNATURE
:
DATE:
FOR OFFICE USE ONLY
Date Received:
Appropriate documentation provided
Notes:
ADA Coordinator Signature: Date:
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ACCESSIBILITY ACCOMMODATIONS REQUEST FORM accommodations@thechicagoschool.edu. (The Chicago School)

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Completed 21 February 2022

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