Fillable SELF-IDENTIFICATION FORM (University of Nebraska, Omaha)

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SELF-IDENTIFICATION FORM (University of Nebraska, Omaha)

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SELF-IDENTIFICATION FORM
Alternate formats of this form are available. Inquire at the front desk.
NU ID: Today’s Date:
Legal First Name: Legal Last Name:
Preferred Name: Pronouns:
(They/Them, She/Her, He/Him, Xe/Xir, Other)
Date of Birth: UNO Email Address: @unomaha.edu
Primary Phone: Alternate Phone:
Is it safe to leave you a voice mail at this number? Is it safe to leave you a voice mail at this number?
No Yes No Yes
Are you currently Admitted to UNO Enrolled at UNO Other
Year in school: Major/Degree:
Transferring from another college/university? No Yes Name:
Who referred you to ASC?
Physical Disability, Psychological Disability, Medical Disability, Learning Disability
Temporary Disability --
Until this date:
Pregnancy – Due date: Duration of leave:
Medical Supervision – Start Date: End Date:
Housing Accommodation Request
1. Please list and describe any disability impairment type(s) affecting you.
The ASC offers support to students through periodic outreach, which might include event notifications, job postings,
scholarship announcements, or wellness and self care reminders. Receipt of this information is purely voluntary.
Is it ok if we send you occasional outreach emails? _____ No _____ Yes
Check all that apply:
2. How does the disability impairment type interfere with your classes and activities?
3. P
lease list any adjustments or accommodations you believe would provide equal access to your UNO classes,
programs, and activities.
SELF-IDENTIFICATION FORM
In order to provide disability-related accommodations, your UNO instructors will receive an official notification from the
Accessibility Services Center. The notification will indicate your name, NU ID, and your accommodation plan. It will not
include any information about your disability or impairment.
Automatic Email Notification
The ASC will automatically send notifications via email to my instructors prior to the commencement of each semester. I
understand the following items:
Emails will be sent for every course that lists an instructor’s name. For courses where no instructor is
(Initials) listed, no email will be sent. In these cases, it is my responsibility as the student to supply the instructor
name and email address to the ASC if I want notification sent.
If I do not receive copies of instructor notification emails before classes begin, it is my responsibility to
(Initials) notify the ASC immediately.
When I receive copies of instructor notification emails, it is my responsibility to check and ensure that the
(Initials) correct accommodations, correct courses, and correct instructors are listed.
It is my responsibility to inform the ASC of any classes that I drop or add after notification emails have
(Initials) been sent.
I understand the pitfalls of email, which can include wrong recipient, lost, deleted, hacked, etc.
(Initials)
I will check that each of my instructors received the notification email.
(Initials)
In conjunction with my instructors receiving the notification email, it is my responsibility to communicate
(Initials) to my instructors directly if I intend to use my accommodations in their class.
Signature: Date:
UNIVERSITY OF NEBRASKA OMAHA
ACCESSIBILITY SERVICES CENTER
6001 Dodge Street • H&K 104 • Omaha, NE 68182 • Phone (402) 554-2872 • Fax (402) 554-6015 • unoaccessibility@unomaha.edu
CONSENT FOR USE OF ALTERNATE SERVICE MODALITIES
In the event of a situation or circumstance requiring social distancing or campus closure (such as
COVID-19 Coronavirus,) Accessibility Services Center (ASC) will adopt temporary alternate
service modalities such as telephone calls or video chats (Skype/Zoom) in lieu of face-to-face
meetings. ASC would be unable to ensure confidentiality in communication through these
platforms, which are limited in technological security.
Please sign and date only one of the options below.
Option (A)
In the event of a service disruption due to any unexpected event, I consent to alternate service
modalities such as telephone calls or video chats (Skype/Zoom.) I understand that
confidentiality cannot be ensured at the same level during this period of disruption as during
regular service. I understand that I may revoke this consent at any time.
Signature of Student NUID Date
Option (B)
I am not interested in using alternate service modalities, and I understand that services will
be limited or unavailable to me until the period of disruption has ended as determined by the
University of Nebraska at Omaha.
Signature of Student NUID Date
UNIVERSITY OF NEBRASKA OMAHA
ACCESSIBILITY SERVICES CENTER
HK 104 • Phone (402) 554-2872 • Fax (402) 554-6015 • unoaccessibility@unomaha.edu • accessibility.unomaha.edu
ASC Accommodation Procedures
Instructor Notifications
• In order to provide disability-related accommodations, UNO instructors will be e-mailed an
official notification from ASC that indicates the student’s name and assigned accommodations.
• The official notification will not disclose any disability-related information.
Student Responsibilities
Please acknowledge your understanding of these student responsibilities by initialing after each
section:
Notification E-mails
• Double check that each instructor received the notification e-mail.
• Notify ASC if notification e-mails are not received 10 days before classes begin.
• Supply ASC with the names of instructors not listed on the class schedule on the first day of
class.
• Inform ASC of any classes that are dropped or added after e-mails have been sent.
Student Initials: ______
Using Accommodations
• Meet and/or correspond (for online courses) with each instructor every semester to devel
op
a
plan for implementing accommodations.
• Communicate with faculty throughout the semester and make requests for accommodations
in a timely manner.
• Keep all e-mails related to accommodations from ASC and instructors.
• After face-to-face conversations, follow up with an e-mail summary for documentati
on
purposes.
Student Initials: ______
Accommodation Support
• Contact the ASC to review accommodations, student responsibilities, and/or matters relat
ed
to faculty communication.
• Contact the ASC with any concerns about accommodations, denial of accommodations, or
other related concerns.
Student Initials: ______
I
have read and understand the information contained in this procedures form.
Signature of Student NU ID # Date
UNIVERSITY OF NEBRASKA OMAHA
ACCESSIBILITY SERVICES CENTER
HK 104 • Phone (402) 554-2872 • Fax (402) 554-6015 • unoaccessibility@unomaha.edu • accessibility.unomaha.edu
Page 1 of 2
Accommodated Testing Procedures
The UNO Testing Center (“TC”) is available to students who have testing accommodations as part of
their accommodation plan developed through the Accessibility Services Center (“ASC.”) Please
observe the following policies and procedures for utilizing the TC for accommodated testing:
Student Responsibilities
Please acknowledge your understanding of these student responsibilities by initialing after each
section:
Meet With Your Professors
• Verify that each instructor received your accommodation plan from the ASC.
• Review each syllabus to find exam dates and testing formats.
• Discuss your testing accommodations with each instructor, and explain any alternate format
conversions that will be required.
• Alternate format conversions should be requested as far in advance as possible to avoi
d
del
ays in material availability.
• If you or your instructor have questions about alternate format arrangements or nee
d
as
sistance converting exam content, contact the ASC.
Student Initials: ______
Schedule Your Exams
• Exams are scheduled by calling 402-554-4800, emailing unotestingcenter@unomaha.edu
,
or
in person at Kayser Hall 522 during TC office hours.
• You must schedule your exam with the TC at least five business days in advance of t
he
ex
amination date.
• You must schedule your exam as close as possible to the same date and time as the
classroom exam date. Any flexibility must be discussed and approved by the instructor prior
to exam date.
• It is strongly recommended that you schedule the entire semester’s exams in advance after
discussing accommodations with your instructors.
• If you have Extended Time as an accommodation, you must schedule for the full ext
ended
t
ime, even if you think you will not use it.
• Testing accommodations must be part of your existing accommodation plan. If you want t
o
m
odify your plan, please contact ASC.
Student Initials: ______
Confirm Your Exam Appointments
• Call TC at 402-554-4800 at least 24 hours in advance to confirm your exam
accommodations.
• Ask if the testing materials have been delivered to TC.
• Verify the precise start time for your exam.
Student Initials: ______
Page 2 of 2
Attend Your Exam Appointments
• Arrive on time. If you arrive more than 15 minutes late, you will be marked as a “no show,”
and if you want to reschedule your exam, your instructor will have to approve it.
• Bring valid photo identification. A UNO MavCard is preferred.
• Store personal items in a TC locker during your exam. Electronic devices are not allowed in
the TC unless specifically permitted by your accommodation plan.
• Food and drink are not allowed in the TC unless specifically permitted by your
accommodation plan.
• Exam sessions are electronically monitored and may be videotaped.
• All students must abide by the University’s policy on Academic Integrity. TC is required to
report any acts of academic dishonesty.
Student Initials: ______
I have read and understand the information contained in this procedures form.
Signature of Student NU ID # Date
UNIVERSITY OF NEBRASKA OMAHA
ACCESSIBILITY SERVICES CENTER
6001 Dodge Street • H&K 104 • Omaha, NE 68182 • Phone (402) 554-2872 • Fax (402) 554-6015 • unoaccessibility@unomaha.edu
ASSISTIVE NOTE TAKING DEVICE AGREEMENT
First Name: Last Name:
NU ID:
TERMS OF AGREEMENT Please initial each section
if you agree.
I will use materials only for my own personal academic use during this
specific course.
I understand that faculty members have copyright interest in their
course materials, and I agree not to infringe on this right in any way.
I will not release, digitally upload, or otherwise share all or part of the
course materials. Additionally, I agree that I will not profit financially and
not allow others to benefit personally or financially from the course
materials.
I understand that any violation of this agreement may subject me to
discipline under the Student Code of Conduct and subject me to liability
under copyright laws.
I understand that ASC will notify my instructors of this agreement.
I understand that I only have the right to use the electronic files for the
academic term of the course.
EXCHANGE OF ANY MATERIALS OR ELECTRONIC FILES, IN A MODIFIED FORMAT OR COPY THEREOF, IS A
VIOLATION OF THE U.S. COPYRIGHT ACT. SEPARATE AUTHORIZATION MUST BE OBTAINED FOR EVERY
USE OF THESE MATERIALS OR ELECTRONIC FILES, ITS MODIFIED FORMAT, OR COPY THEREOF.
My signature below indicates that I have read, understood, and will abide by all the terms and conditions
of this contract, with no exceptions.
Signature: Date:
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Completed 2 February 2021

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