Fillable CALIFORNIA STATE UNIVERSITY, FULLERTON ACCESSIBLE FURNITURE REQUEST FORM (California State University, Fullerton)

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CALIFORNIA STATE UNIVERSITY, FULLERTON ACCESSIBLE FURNITURE REQUEST FORM (California State University, Fullerton)

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CSUF Email:
Contact Phone:
Campus-Wide ID#:
Student Name:
ACCESSIBLE FURNITURE REQUEST FORM
Request for:
Year
@csu.fullerton.edu
▪ It is MY responsibility to meet with my DSS counselor at least ten (10) working days prior to the start of the
semester if I would like my prescribed furniture accommodations to be reviewed and modified.
▪ It is MY responsibility to submit my furniture request to the DSS office in a timely manner to allow at least ten
(10) working days to process and fulfill my request.
▪ It is MY responsibility to inform DSS immediately should there be any change in my class schedule, classroom
location, cancellation of service, or any questions or concerns.
▪ It is MY responsibility to notify DSS immediately if furniture is missing or damaged during the time it is
assigned to me, so it can be replaced.
I have read and agree to the above responsibilities and statements.
Date:Student Signature:
ChairTable
Furniture Request
Specify type of table/chair:
Do you use a wheelchair?
NoYes
If yes, wheelchair is:
ManualElectric
Width/Height of chair:
Class Schedule
List only those courses for which you are requesting furniture
Semester
(cell, home, or work)
Class #
Class #
Class #
Class #
Class #
Class/Section
Class/Section
Class/Section
Class/Section
Class/Section
Instructor
Instructor
Instructor
Instructor
Instructor
Day/Time
Day/Time
Day/Time
Day/Time
Day/Time
Location
Location
Location
Location
Location
CALIFORNIA STATE UNIVERSITY, FULLERTON
Disability Support Services
Date:Request approved per DSS Staff:
FOR OFFICE USE ONLY
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CALIFORNIA STATE UNIVERSITY, FULLERTON ACCESSIBLE FURNITURE REQUEST FORM (California State University, Fullerton)

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Completed 22 July 2020

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