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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