HAWKEYE COMMUNITY COLLEGE
STUDENT REASONABLE ACCOMMODATION REQUEST
FOR ACCUPLACER
NAME: __________________________________SSN:________________________BIRTHDATE:_______________
ADDRESS: _________________________CITY:______________________STATE:________ZIP:_______________
PHONE: __________________ EMAIL:_______________________________________________________________
STARTING DATE AT HCC: ________________________________
THIS FORM SHOULD BE COMPLETED WHEN A STUDENT WANTS TO REQUEST A REASONABLE ACCOMMODATION
FROM THE COLLEGE. UPON COMPLETION, THIS FORM MUST BE DELIVERED TO THE SPECIAL NEEDS
COORDINATOR AND KEPT SEPARATE FROM THE STUDENT’S GENERAL ENROLLMENT FILE.
TO BE COMPLETED BY THE STUDENT. IT IS THE RESPONSIBILITY OF THE STUDENT TO PROVIDE
DOCUMENTATION OF A DISABILITY. REQUESTS WILL ONLY BE REVIEWED ONCE DOCUMENTATION
HAS BEEN RECEIVED.
1. IDENTIFY AND DESCRIBE THE LEARNING, PHYSICAL OR MENTAL DISABILITY, ILLNESS, CONDITION, OR
DISEASE WHICH IS THE BASIS FOR YOUR REQUEST FOR REASONABLE ACCOMMODATION(S) BY THE COLLEGE:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
2. CHECK THE ACCOMMODATION(S) YOU ARE REQUESTING.
Testing Accommodations for: _____________ MATH ____________ WRITING __________ READING
_____ Interpreters (Sign Language) _____ Separate Testing Room
_____ Enlarged Screen Font Size ______
_____ Tests Read/Audio Test
_____ Scribe for Writing Sample
_____ Braille Test
_____ Other_________________________________________________________________________________________________
_____ Other_________________________________________________________________________________________________
SIGNATURE:___________________________________________________________ DATE:_________________________________________
COMPLETE AND RETURN TO:
Student Services, Special Needs Coordinator
Hawkeye Community College
P.O. Box 8015
Waterloo, IA 50704-8015
PHONE: 1-800-670-4769 * PHONE: 319-296-4014
FAX: 319-296-1028
EMAIL: specialneeds@hawkeyecollege.edu
