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
12. AUTHORIZATION for RELEASE OF INFORMATION
I hereby authorize the release of information summarized in this Support for Accommodation
Request for the purpose of evaluating eligibility and accommodation requests.
Name of Student (Printed) Student’s Signature
Date
13. STUDENT WRITTEN RESPONSEStatement of Goals (Please write your statement of at least
3-5 sentences describing what you hope to accomplish in the next year.)
EVALUATION
: For: http://ahead.org/survey/iowa/dss/dss.php Username: IowaPostsecondary Password: SARpse
For: http://ahead.org/survey/iowa/secondary/secondaryprov.php Username: IowaSecondary Password SARse
SAR Revised 7/28/09