SUPPORT FOR ACCOMMODATION REQUEST
To be used in consideration of post-secondary academic accommodation requests.
Student’s Name:
1.
ELIGIBILITY/DIAGNOSTIC STATEMENT:
• Date of original eligibility:
• Most recent reevaluation date:
• Current goal area(s) of concern:
2.
FORMAL DIAGNOSIS and DATE (when available):
3.
What is the BASIS OF DETERMINATION for current services? (Provide available diagnostic
assessment information and recent evaluation results; include performance levels with/without accommodations.)
4. Describe the CURRENT FUNCTIONAL IMPACT of the disability:
5. RESPONSE TO specially designed INSTRUCTIONAL INTERVENTION:
6. Expected PROGRESSION or STABILITY of the disability:
7. HISTORY of ACCOMMODATIONS:
• 9
th
Grade:
• 10
th
Grade:
• 11
th
Grade:
• 12
th
Grade:
8. SUGGESTED ACCOMMODATIONS for post-secondary experiences:
9. RECOMMENDATIONS (include accommodations, linkages to adult services, other support) for
• Living:
• Working:
10. ADULT/COMMUNITY Contacts:
• Agency: Status: Name/Position: Telephone:
11. SIGNATURE of Credentialed Professional
Name of Person completing this form (Print) Title/Role Agency/Organization
Signature Telephone
Date
Continue on next page.
click to sign
signature
click to edit
![]()
