Accommodation Request
Revised 8/11/15
Submission Instructions
Please complete this form in its entirety and return to the Office of Student Access and Wellness.
Tel: 866.974.5700 Ext. 20050 Fax: 866.251.5407 access@ashford.edu
Note: Please review the accepted form formats: .PDF, Word (.DOC or .DOCX), Excel (.XLS or .XLSX), TIFF or .TIF, .JPG or .JPEG, Text (.TXT),
Bitmap (.BMP), .HTML or .HTM Submitting a form in any other format may require resubmission or result in a delay in processing
.
Ashford University prohibits discrimination on the basis of a disability in accordance with Section 504 of the Rehabilitation Act of
1973, and the Americans with Disabilities Act (ADA) of 1990, as amended. The University is committed to providing an equal
opportunity to access a full educational experience and reasonable accommodations will be granted to students who document a
disability and are otherwise qualified to participate in the specific academic program or activity.
Student Information
Student Name: __________________________________________________ Student ID: __________________________
Preferred Contact Method:
Phone _______________________ Email ___________________________________
Major/Program of Study: ___________________________________________
Program Modality: Online Campus
Student Acknowledgement
Student acknowledges the following in order to initiate a request for accommodation. Check each box below:
It is my responsibility to advise Student Access and Wellness professional staff of the disability related impacts I
experience in the learning environment and the potential accommodations that may support my learning.
I am aware that Student Access and Wellness professional staff may request third party documentation of my
disability and that it is my responsibility to obtain and provide such documentation.
I understand that accommodation requests are reviewed and authorized by Student Access and Wellness
professional staff.
I understand that accommodations are not retroactive and should be requested in advance for each University
course or activity.
Student privacy is a fundamental goal of Ashford University and the Office of Student Access and Wellness. I
understand that professional staff may disclose information maintained in my disability file only to school officials
who have a legitimate educational need to access these records.
Accommodation Request
Diagnosis or nature of my disability and related impacts (required):
Specific accommodation(s) which may support my learning (required):
S
tudent Signature: _________________________________________________________ Date: ____________________
Type name for Electronic Acknowledgement
Ashford University Disability Documentation Policy
The process for determining accommodations is a collaborative one that may or may not require third-party documentation.
One or more of the following documentation categories will be considered in the evaluation of student accommodation
requests:
1. Primary Documentation: Student’s Self-Repor
t
A
shford University believes the student is a vital source of information regarding how he or she may be “limited by
impairment.”
i
A student’s narrative of his or her experience of disability, barriers, and effective and ineffective
ac
commodations is an important tool which, when structured by interview or questionnaire and interpreted b
y
pr
ofessional staff, may be sufficient for establishing disability and a need for accommodation.
2. Secondary Documentation: Observation and Interaction
The impressions and conclusions formed by Ashford University disability professionals during interviews an
d
conversations with students or in evaluating the effectiveness of previously implemented or provisional
accommodations are important forms of documentation. The University employs qualified and experienc
ed
di
sability professionals who will observe students’ language, performance, and strategies as an appropriate tool i
n
v
alidating student narrative and self-report.
3. Tertiary Documentation: Information from External or Third Parties
Documentation from external sources may include educational or medical records, reports and assessments
created by health care providers, school psychologists, teachers, or the educational system. This information is
inclusive of documents that reflect education and accommodation history, such as Individual Education Program
(IEP), Summary Of Performance (SOP), and teacher observations.
ii
External documentation will vary in its
relevance and value depending on the original context, credentials of the evaluator, the level of detail provided, an
d
t
he comprehensiveness of the narrative.
These guidelines apply to students taking Ashford University courses. Please be aware that other universities and testing
agencies (which administer standardized tests such as the Graduate Record Exam and Law School Admission Test) may
require more extensive documentation, and you should check their requirements well in advance.
All questions regarding documenting your disabilities should be directed to
access@ashford.edu or
866.974.5700 ext. 1000.
i
Disability is defined by the ADA as “a physical or mental impairment that substantially limits one or more of the major life
activities, a record of such an impairment or being regarded as having such an impairment.”
42 U.S.C 126 §12102
ii
Revisions to Title III regulations provide, “When considering requests for modifications, accommodations, or auxiliary aids
or services, the entity gives considerable weight to documentation of past modifications, accommodations, or auxiliary aids
or services received in similar testing situations, as well as such modifications, accommodations, or related aids and
services provided in response to an Individualized Education Program (IEP) provided under IDEA or a plan describing
services provided pursuant to section 504 of the Rehabilitation Act of 1973”
(28 C.F.R. § 36.309(b)(1)(v))
Guidance and Section-by-Section Analysis provides these examples of types of information to consider: “recommendations
of qualified professionals familiar with the individual, results of psycho-educational or other professional evaluations, an
applicant’s history of diagnosis, participation in a special education program, observations by educators, or the applicant’s
past use of testing accommodations.”
28 CFR Part 36 (2010)