Fillable Office of Disability Services (ODS) Smith College School (Smith College)

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Office of Disability Services (ODS) Smith College School (Smith College)

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The Office of Disability Services (ODS) Smith College School (Smith College) form is 6 pages long and contains:

  • 2 signatures
  • 37 check-boxes
  • 103 other fields

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File type: PDF

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Office of Disability Services (ODS)
Smith College School for Social Work
Accommodations and Services Request Form
● Please complete ALL SECTIONS of this form.
● A new form must be submitted for course accommodations each summer.
● Please remember to also complete the Field Accommodations section of this form to request
academic and placement related accommodations.
● Medical and/or educational information about your disability must be provided to ODS.
● Requests for new or changed accommodations will be reviewed before approval. You will be
notified if additional documentation is needed.
● Retroactive accommodations cannot be provided.
● If your address (permanent or on-campus) changes, please notify ODS immediately.
Student Information
Accommodation request for:
Field Summer
Today’s Date
Name (include the pronoun you use) House:
Room #:
Home
Address:
Phone E-mail:
Are you living off-
campus this summer?
Yes No
Academic
Advisor:
Faculty Field
Advisor:
Student ID:
Disability:
Please explain your disability and/or the challenges you are experiencing:
Documentation provided to the Office of Disability Services? Yes No
Date:
Address:
Semester Course Schedule - Term 1
Course Number/section Instructor Instructor’s email
1.
2.
3.
4.
5.
Semester Course Schedule - Term 2
Course Number/section Instructor Instructor’s email
1.
2.
3.
4.
5.
Do you need Housing Accommodations? Yes
No
Please explain:
Service Animals and Emotional Support Animals
____I am bringing a trained service animal (dog) with me to campus.
____ I would like assistance communicating with my faculty about the presence of my
service animal (dog) in classes.
____I am requesting permission to have an emotional support animal live with me in the
residence hall. Type of animal requested:
Note: Please complete all necessary animals in housing contract forms on the
ODS website.
Academic Accommodations/support for summer courses (check all that
apply)
Type of Accommodation Please explain:
Sign Language Interpreter/FM
System or other listening
device
Communication Assistance
Assistive Technology
Special Furnishings in
classrooms
Captioning
Books/materials in alternative
format
Classroom Note taker
Extensions for written
assignments or projects
Excused Absences
Assistance with Organization
and planning/learning skills
Other (please specify)
Other (please specify)
Dietary Accommodations Needed:
Dietary concern
Food Allergies/sensitivities
Please list all allergies:
Have you been in touch
with Dining services?
Yes No
Do you have a diet that is prescribed by a physician or nutritionist?
Yes No
Please attach a copy of the diet or provide a doctor’s letter.
Other food challenges:
Services or Information Needed (check all that apply):
Topic Topic
Help finding physician,
therapist or psychiatrist
Internships and job resources
JYA or travel abroad questions Finding help, personal care assistant, or house
cleaning
Wheelchair repair service Financial aid/ Work study
Help finding learning or writing
coach.
Support group
Need information about
community resources
Off campus transportation
Questions about LD/ADHD
testing
Other: (please specify)
Assistive technology for
personal use
Do
you need support with writing or learning strategies? Yes No
Please explain:
Additional Comments:
Field Placement Accommodations (check all that apply)
I will need job related accommodations during my field placement: Yes No
Placement Agency Name, address, and Phone: Name/title of supervisor:
Type of Accommodation Please explain
Sign Language Interpreter/FM
System or other listening device
Other Communication
Assistance (please specify)
Special Furnishings in the
workplace
Captioning
Assistive Technology
Books/articles in alternative
format (please specify)
Flexible scheduling
Instruction/Supervision
Extensions on written work
Location
Transportation
Other
Other
_____I will need accommodations for written academic assignments and projects during
my year in field.
Please list each assignment and accommodation requested:
ODS notes:
PLEASE SIGN (Your request will not be processed without a signature)
I authorize the Office of Disability Services to obtain information from and communicate with my
providers about my disability.
Signature ________________________________ Date _________________
I have also completed a release form allowing ODS and the School for Social Work to communicate
regarding accommodations and supports I will need during the program. This may include faculty, Deans,
and professional staff at Smith College when necessary to determine, clarify and implement my need for
specific disability-related accommodations.
Signature ________________________________ Date _________________
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Office of Disability Services (ODS) Smith College School (Smith College)

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Completed 26 August 2020

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