Fillable APPENDIX A APPLICATION FOR ACCOMMODATIONS & SERVICES Section (Touro College)

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APPENDIX A APPLICATION FOR ACCOMMODATIONS & SERVICES Section (Touro College)

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APPENDIX A
APPLICATION FOR ACCOMMODATIONS & SERVICES
Please allow up to 21-days for the Office of Student Disability Services (OSDS) to review your
application and supporting documentation. Please note that your application cannot be reviewed until
all documentation is received. General Documentation Guidelines are outlined below. After OSDS
has reviewed your application, you will be contacted via e-mail or by phone so that we may engage
you in an interactive dialogue relative to your application. Please contact OSDS if you have questions
regarding the OSDS application process.
Section I: Student Information
Today’s Date: _____________
Name: ____________________________________________________
Student ID Number:_______________________________________
Date of Birth: _____________________
Preferred Title (Mr., Ms., etc.):________________
Permanent Address:
(Street & Apt. #)
(City) (State) (Zip)
Local Address:
(Street & Apt #) (City) (Zip)
Phone #:_________________________________________________________________
Touro E-mail Address:______________________________________________
Other E-mail Address:__________________________________________________________
Touro College School: _________________________________
Program: _________________________________
Campus: _________________________________
Anticipated Graduation Date: _________________________________
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Section II: Disability Related Information
Please answer the following questions regarding your disability and how it impacts your ability
to learn, attend, or participate in College life.
1. Please indicate your disability category(ies). Check all that apply:
A. Neurodevelopmental
□ ADHD
□ Autism Spectrum Disorder (including Asperger’s Syndrome)
□ Communication/Speech: communication disorders, including apraxia of speech;
articulation disorder; phonemic disorder; stuttering; voice disorder
□ Learning Disability: includes central auditory processing disorder; disorder of written
expression; dysgraphia; dyscalculia; dyslexia; learning disorder NOS; mathematics
disorder; mixed receptive-expressive language disorder; nonverbal learning disorder (if
student has not been diagnosed on the autism spectrum); processing speed disorder; reading
disorder; visual processing disorder
□ Motor: developmental coordination disorder; stereotypical movement disorders; tic
disorders; tremors
B. Sensory
□ Blind: visual acuity of 20/200 or worse in the better or stronger eye with the best
correction; totally blind; or a person with 20 degree or less field of vision (pinhole vision).
□ Low Vision: visual acuity of 20/70 or worse in the better eye with best correction; a total
field loss of 140 degrees or more in the field of vision; difficulty in reading regular
newsprint even with vision corrected by glasses or contact lenses; loss of vision in one eye
□ Deaf: not able to discern spoken communication by sound alone; a hearing loss that
prevents one from totally receiving sounds through the ear, whether permanent or
fluctuating
□ Hard of Hearing: partial hearing loss; may be conductive, sensorineural, or both
C. Mental Health
□ Generally, disorders characterized by dysregulation of mood, thought, and/or behavior.
These include anxiety disorders, eating disorders, mood disorders and psychotic disorders.
D. Physical
□ Basic Chronic Medical Condition: a medical condition resulting in limited strength,
vitality or alertness due to chronic or acute health problems. This would not include those
with temporary disabilities.
□ Mobility: indicates a student who, typically, must use a standard manual or electric
wheelchair or other assistive device (walker, crutches, braces, prosthesis, etc.) to move
from place to place.
□ Orthopedic: a physical disability caused by congenital anomaly, diseases of the bones
and muscles, connective tissue disorders, or other causes. This would not include those
with temporary disabilities.
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E. Intersystem (existing between two or more systems)
□ Alcohol/substance addiction and recovery: students who are recovering from drug or
alcohol or substance abuse or who are in substance abuse treatment programs
□ Complex Chronic Medical Condition: a medical condition that significantly affects
multiple systems of the body. This would not include those with temporary disabilities.
□ Traumatic brain injury: an injury caused by an external physical force (concussion) or
from certain medical conditions (aneurysm, anoxia brain tumors, encephalitis, stroke) with
resulting mild, moderate or severe disabilities in one or more areas (abstract thinking,
attention, cognition, information processing, judgment, language, memory, motor abilities,
perceptual, physical functions, problem solving, psychosocial behavior, reasoning,
sensory, speech). The term does not include injuries that are congenital or birth-related.
F. Temporary Disabilities
□ A transitory impairment with an actual or expected duration of six months or less.
Examples include bone fractures, sprains, torn ligaments, post-surgical recoveries,
significant illness, etc.
□ Pregnancy-related condition.
G. Multiple Disabilities
□ A student with two or more disabilities.
H. Other
□ Please specify:__________________________________________________________
2. Specify the diagnosis or type of disability based on the category above:
3. Please check all that apply:
□ I use a wheelchair.
□ I use assistive mobility devices (braces, crutches, cane, or prosthesis).
□ I wear a hearing aid.
□ I need to read lips of instructors.
□ I have difficulty reading the blackboard/whiteboard.
□ I have difficulty taking notes in class.
□ I have difficulty writing.
□ I have difficulty standing for long periods of time.
□ I tire easily when I walk distances.
□ I have difficulty walking up/down stairs.
□ Please describe any other mobility or disability related difficulties you are currently
experiencing:
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□ Other
4. Are you currently taking any medication related to your disability or medical condition?
Yes No (check only one)
If yes, list all of the medications you are taking:
If yes, please also list any side effects of the medications that you are taking and their positive
and negative impact on your academic/cognitive abilities and/or other activities:
5. Please check all of the reasonable accommodations that you are requesting:
Testing Accommodations
• Please specify _______________________________________________________
Classroom Accommodations
• Please specify: _______________________________________________________
Communication Accommodations
• Please specify:_______________________________________________________
Other Accommodations
• Please specify: _______________________________________________________
6. Please list any services/accommodations you received throughout your education (Please
note that while such services do not necessarily carry over to your current program, the information
is helpful to give OSDS background information on your disability-related needs.)
Institution: __________________________________ Years Attended: ___________________
Accommodation(s) Received:
Institution: ___________________________________Years Attended: ___________________
Accommodation(s) Received:
Section III: Agency Information
Do you receive services from any of the following agencies?
Vocational Rehabilitation Services
• Specify State and Agency:
Veterans Administration (VA)
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Other:
Section IV: Application Certification
I, _____________________________, certify that the foregoing statements are complete,
accurate, and true to the best of my knowledge, and I understand that Touro College requires
supporting documentation.
Signature of Student Date
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APPENDIX A APPLICATION FOR ACCOMMODATIONS & SERVICES Section (Touro College)

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Completed 21 July 2020

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