Fillable STUDENT REQUEST FOR DISABILITY SERVICES (New Mexico Institute of Mining & Technology)

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STUDENT REQUEST FOR DISABILITY SERVICES (New Mexico Institute of Mining & Technology)

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Revised 6-20 TEK
1
□
Office for Disability Services
Fidel Center Room, 154
575-835-6209
disability@nmt.edu
https://nmt.edu/disabilityservices.php
STUDENT REQUEST FOR DISABILITY SERVICES
Th
is form is to be completed by the STUDENT. (If assistance is needed, please ask the Disability Case Manager
Fill out the form as completely as possible prior to meeting with the Disability Case Manager.
Date: Banner ID: 900
Nam
e: DOB:
PO
Box C/S #: Physical Address:
Cit
y: ________________________ State: ________________________ Zip: ________________________________
Ho
me address
(if different than physical address): _________________________________________________________
Ci
ty: __________________________ State: ______________________ Zip: ________________________________
NMT
email: _______________________________________________________ Phone #: _____________________
By p
roviding an emergency contact you give New Mexico Tech permission to contact this person in an emergency.
Em
ergency contact: _______________________________________ Relationship: _________________________
Em
ail: Phone:
Yea
r in school □ Freshman □ Sophomore □ Junior □ Senior □ Graduate
Student Status □ Full-time □ Part-time □ Prospective
ACADEMIC DATA:
Is this your first semester at Tech? □ YES □ NO
If
not, date of first semester at Tech: Are you a transfer student? □YES □ NO
Maj
or area of study: ________________________________Advisor: ____________________________________
Current GPA: _____________ How are your grades this semester: □ Excellent □ Good □ Fair □ Poor
Has
your academic performance changed? □ YES □ NO
If ye
s, how? ____________________________________________________________________________________
Do
you have a Tech scholarship or the New Mexico Lottery Scholarship: □YES □ NO
If
yes please list:
@student.nmt.edu
Revised 6-20 TEK
2
EMPLOYMENT DATA:
Are you working? □ YES □ NO
Place of employment: _______________________________________ Hours per week:
DISABILITY INFORMATION:
Diagnosis or type of disability:
Date you were diagnosed: Name of Diagnostician:
Date of most recent diagnosis
Medications currently prescribed for your disability, please list and describe:
1) 2)
3) 4)
Do you currently have a primary care provider for your disability? □ YES □ NO
Name and Profession:
Physical Address:
City: State: Zip:
Email: Phone #:
Check the major life activities/major bodily function your disability currently “substantially limits”
Include, but are not limited to:
□ Bending □ Endocrine □ Respiratory
□ Bladder □ Hearing □ Seeing
□ Bowel □ Immune System □ Sleeping
□ Brain □ Interacting with others □ Speaking
□ Breathing □ Learning □ Standing
□ Caring for self □ Lifting □ Thinking
□ Circulatory □ Neurological □ Walking
□ Communicating □ Normal cell growth □ Working
□ Concentrating □ Performing manual tasks □ Other ________________________
□ Digestive □ Reading
□ Eating □ Reproductive functions
Revised 6-20 TEK
3
How does your disability limit your academic performance?
Please describe the issues that you are experiencing in class/housing/other setting that require accommodations
Have you received accommodations for your disability in the past: □YES □ NO
Where and what accommodation/s (list previous institutions and accommodation/s):
Check any of the following outside agencies from which you have received support:
□ CMC-Randolph □ VA
□ Services for the Blind □ Vocational Rehabilitation
□ Services for the Deaf and Hard of Hearing □ Other:
What services did this agency provide?
Which of the following tasks do you HAVE DIFFICULTY doing? (check all that apply)
□ Communication □ Memorizing □ Reading/Understanding
□ Finishing Tests on time □ Paying Attention □ Spelling
□ Following directions □ Putting Thoughts into words □ Taking notes
□ Math calculations □ Physical Activities □ Time Management
□ Writing
ACCOMMODATION REQUESTS
Please describe the reasonable accommodations you are requesting:
Any other concerns that you would like to discuss:
NOTE: Accommodations are approved based on the supporting documentation provided, an intake
interview with a case manager, and may include decisions by the Office for Disability Services team.
Revised 6-20 TEK
4
NMT Student Agreement for Disability Services and Accommodations
My signature below affirms that I am registering with New Mexico Tech’s Office for Disability Services (ODS)
as a student with a disability, as defined by the Americans with Disabilities Act and Section 504.
I understand that despite my disability (Please initial each):
I fully understand that this request for accommodation(s) is based on New Mexico Tech’s need for
documentation to support my request for services.
I understand that once this request for accommodation(s) is processed, I may be required to provide
additional documentation, on a case-by-case basis, of changes in my condition. I understand NMT may not be
able to provide services until appropriate documentation has been received.
I agree to allow the disclosure of my agreed upon accommodations to my professors. I am aware that it is
my responsibility to deliver and discuss my accommodation letters with each professor. I understand that
choosing not to utilize accommodations is my choice, but they may not be used retroactively.
I understand that ODS may have student workers assisting with filing of records. I understand my
information may be shared with those within the University who have a legitimate educational interest.
I must meet the academic standards as set forth by my program of study and the classes I take, with or
without accommodations.
I am responsible for following the Universities’ policies and the New Mexico Tech Student Handbook: A
Guide to University Citizenship.
I am responsible for contacting ODS each semester to review my accommodation(s).
I understand that most contact with the Office for Disability Services will go through my student email
account at New Mexico Tech.
If I desire to have any information disclosed with outside parties, including my parents; I will sign a release
of information form with ODS.
I understand that student or faculty questions about accommodations should be submitted to ODS.
I, the undersigned, authorize the staff providing disability accommodation services to contact relevant New
Mexico Tech student services staff, faculty or administration to share information pertaining to my
accommodation(s) for the purpose of coordinating appropriate services and determining any necessary and
reasonable academic accommodations.
Student Signature Date:
NMT ODS Representative Signature: Date:
The institution will provide ac
commodations to students with disabilities to enable students to meet institutional
standards without compromising the Academic Integrity of the course, program, assignment or activity.
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STUDENT REQUEST FOR DISABILITY SERVICES (New Mexico Institute of Mining & Technology)

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Completed 23 July 2020

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