Fillable Request for Accommodations nline Buena Vista University O (Buena Vista University)

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Request for Accommodations nline Buena Vista University O (Buena Vista University)

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Online Accommodations
Request for Accommodations
Buena Vista University – O
nline
Name: Date:
Date of birth: BV ID #
City/State:
Documentation of Disability
• The student is responsible for providing documentation from a professional service
provider (such as a physician, psychiatrist, educational psychologist) to the Director of
the Center for Academic Excellence (CAE) This documentation must include the
description of the disability; names and results of tests administered (if appropriate); the
effect of the disability on student’s ability to access University programs, services and
activities; and suggestions for specific accommodations that would provide access to
University programs, services, and activities
• Documentation will be kept in the student’s confidential file.
• The 504 Coordinator and/or the Director of Academic Excellence reserve the right to
obtain clarification of the diagnosis of the disability, limitation, and accommodation
needs, if necessary.
Disability
State diagnosed disability:
Please provide any additional information regarding the characteristics of your disability:
Online experience
Have you taken an online course before? Yes No
If yes, did you use accommodations? Yes No
What accommodations have you used in the past for online classes?
What were the results of these accommodations?
Online Accommodations
Educational History
Major:
Advisor’s name:
Planned Attendance: Full-time (6 hours/term for 2 terms)
Part-time
Status: First-year (less than 30 hours) Junior (60-89 hours)
Sophomore (30-59 hours) Senior (90+ hours)
Graduate Student
Current GPA Cumulative GPA
Are you an “online only” student: Yes No
If no, what is your enrollment status?
Accommodation and Service Needs:
Determination of eligibility for accommodations will be made based upon the documentation
provided and discussion with the student. Accommodation for courses may vary depending on
the nature of the course.
What accommodations have you used in the past for face to face classes?
What were the results of these accommodations?
Have you had any accommodation request turned down by BVU or another institution?
Yes No
If yes, please explain:
Online Accommodations
Accommodations you are requesting:
Please list any additional information which may be helpful to your request.
Available Assistive Technology:
What assistive technology do you use?
What version?
Have you used this assistive technology with any other classes on Angel (platform)?
What success have you had with this?
___ I certify that the information in this form is correct and complete.
Online Accommodations
Authorization for Release of Information
I hereby authorize the representatives of the 504 Coordinator and/or the Director of the Center for
Academic Excellence (CAE) at Buena Vista University to be permitted to review and obtain copies of
information concerning my health, academic, and assessment records for the purpose of evaluating
eligibility and accommodation requests.
I further authorize these representatives to be permitted to release, discuss, and exchange disability and
accommodation request information with Buena Vista University faculty, staff, or affiliated rehabilitation
agencies in order to provide full coordination of services.
I agree that any person(s) who may furnish information concerning my records or test data or
therapist/counseling notes shall not be held accountable for releasing this information; and I do hereby
release said person(s) from any and all liability for damages of whatever kind which may at any time
result to me, my heirs, and family or associates because of compliance with this authorization and release
of information, or any attempt to comply with it.
I further release Buena Vista University from any and all liability for damage of whatever kind which
may at any time result to me, my heirs, and family or associates because of compliances with this
authorization, or any attempt to comply with it.
I understand that I may revoke this authorization at any time, except to the extent that action has already
been taken in reliance upon it, by giving written notice to the 504 Coordinator and/or the Director of the
CAE.
Print student’s name
Student’s signature Date
Notes/Comments: (for office use only)
The 504 Coordinator and the Director of the CAE do not have permission to communicate
with the following individuals:
Print name Title
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Request for Accommodations nline Buena Vista University O (Buena Vista University)

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Completed 18 August 2020

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