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Virginia State University
Housing Accommodation Request Form
To have your request for a housing accommodation considered, please submit a completed
application by the indicated deadline as well as complete the housing process as indicated
through the Department of Residence Life and Housing.
Par
t I: To be completed by the student
Student Name: _______________________________________________ Date: ___________
V#_____________________________ Email Address: ____________________ @students.vsu.edu
Address: ______________________________________________________________________
Home Phone: _____________________________ Cell phone: ____________________________
Current Academic Level: ___Freshmen ___Sophomore ___Junior ___Senior ___Graduate
Semester Requesting Accommodations: Fall______ Spring______ Summer______
Do you have any Medical, Psychological, Physical or Disability Related Conditions that would affect
your housing assignment?
Yes No (If yes, check all that apply)
Please indicate your diagnosis/diagnoses for which you are requesting a housing accommodation:
Please check the housing accommodations being requested for the term indicated.
o Single Room*
o Wheelchair access to elevator
o Private/semi-private bathroom
o Wheelchair accessible furnishings
o Air conditioning
o Lowered shower bars
o ADA compliant bathroom (including roll
in shower)
o Room with additional space for medical
equipment
o First-floor room access
o Room with less allergens
o Wheelchair accessible dorm
o Lowered desk, bed, closets
o Proximity to buildings (specify)
______________________________
o Visual doorbell (typically for students
with hearing impairments
o Other: ________________________
o Other: _________________________
*
Single room accommodations are determined on a case-by-case basis and are limited by
room space availability.
Student Name: ________________________________
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Explain how the requested accommodation(s) relates to your medical diagnosis/diagnoses or
disability.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What alternatives may work in lieu of the accommodations requested?
If you are specifically requesting a single room accommodation and that request is unable to be
honored, would you be willing to be placed with a student needing a similar accommodation?
___ Yes ___ No
Is the accommodation for a temporary or permanent condition:
Are you requesting academic accommodations for the same term? ___ Yes ___ No
(If yes, please see the Student Accessibility Office for intake forms)
Important Information
Housing Accommodation Form Deadlines:
M
ay 1
st
for first year and transfer students
April 5
th
for returning students
Housing deposit for new students or housing advance for returning students must be paid for
an application to be considered.
All requests will be prioritized in the order they are received.
Applications received after the stated deadline will be reviewed based on an availability
basis. All housing requests are evaluated on a case by case basis.
Students will be notified by email to the address on file with the university.
Student Certification
I have provided accurate information to be used for housing accommodations at Virginia State
University. I am aware it is my responsibility to meet all deadlines and submit any required
documentation.
____
_______________________________ ____________________________
Student Name (Print) Date
____
_______________________________ ____________________________
Student Name (Signature) V#
(If temporary, please provide expected duration)
(If temporary, please provide expected duration)
Student Name: ________________________________
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Part II: To be completed by the physician
Physician/Provider Name: ______________________________________________________________
Name of Practice: _______________________________________________________________
Title: _______________________________________
Address: _______________________________________________________________________
City, State, Zip: _________________________________________________________________
Phone: __________________________________ Fax: _________________________________
Email: ________________________________________________________________________
Diagnosis/Diagnoses of Medical Condition(s), Psychological Disorder or Primary Disability
List Diagnosis/Diagnoses:
_____________________________________________________________________________________
Original date of diagnosis/diagnoses:
_____________________________________________________________________________________
Date of Most Recent treatment or diagnosis/diagnoses:
_____________________________________________________________________________________
List medication used for treatment for the condition(s): ___________________________________
Prognosis for Diagnosis/Diagnoses:
_____Permanent/Chronic _____6-12 months _____6 months or less _____episodic
Severity of the Condition:
____Mild ____Moderate ___Severe
Please provide detailed information concerning the nature and extent of the disability:
Provide specific information on the functional limitation as related to the academic environment:
Student Name: ________________________________
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Describe the current course of treatment including medication side effects:
Please provide the prognosis for the disability:
Please list any housing accommodations you recommend for the student and give justification for each
recommendation (be specific in sharing how the accommodation(s) or modification(s) is medically
necessary/required for the student to have equal access to the residence hall; and,
in the case of a single
room request
, describe how a shared space will adversely impact the student’s ability to live in the residence
hall).
In the space provided, please address the following:
If accommodations are not met, will there be a negative health impact for the student?
What other alternative to accommodations could satisfy as reasonable accommodations?
Please check which of the following major life activities is substantially limited by the disability:
__ Seeing __ Eating __ Reading
__ Walking __Sleeping __Learning
__ Lifting __ Bending __ Thinking
Student Name: ________________________________
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__ Hearing __Speaking __ Concentration
__ Standing __ Breathing __ Communicating
__Working __ Organizing information __Use of bodily functions
Other(s): _____________________________________________________________________________
S
ignature below certifies records for this student are on file and the physician/provider will be
available for clarification upon request.
____________________________________ ________________________
Physician/Provider Signature Date
____
________________________________
Physician/Provider Name
If practice stamp is available, please place stamp in this space:
P
lease return all documents to:
Virginia State University
Student Accessibility Office
Memorial Hall
1 Hayden Drive
Petersburg, Virginia 23806
(804) 524-5061
(804)
52
4-5978 Fax
sao@vsu.edu
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