Virginia State University
Student Accessibility Office (SAO)
Reasonable Accommodation Request Contract
CONFIDENTIAL
Student Name: ________________________________ V#: V00________________ Date: _______________
Student’s Email Address: ___________________________ Student’s Cell Phone #: ______________________
During this session, it was suggested that the above named student receive the following reasonable accom-
modations during the Fall Spring Summer (please circle the current semester) ___________ (year).
SAO Recommendation Accommodations:
Student: Please Initial ONE of the following:
_______ I agree to the recommended accommodations as indicated above, by check mark.
_______ I do not agree to the recommended accommodations as indicated above, by check mark.
Please note:
Accommodations must be requested by the student each semester. If you decide to request accommoda-
tions at a later date, you may do so. However, SAO must be notified immediately regarding this change.
Once the request has been completed and submitted, accommodation letters will be sent to professors elec-
tronically within 10 business days of the request. The student will be copied on the email to ensure clarity
(between the student, the faculty member, and the SAO office) of the accommodations being provided.
Once the letter is returned back to the office via email, it will be placed into the student’s confidential file.
If you are taking an online course (away from VSU campus) and are not available to sign your reasonable ac-
commodations request form, one of the SAO designees will print your name and sign theirs, in your absence.
You will then be provided with the reasonable accommodation letter, via email, from the SAO.
Signature: _____________________________________________ Date: _________________________
(Student)
Signature: _____________________________________________ Date: _________________________
(Designee)
Revised 7/16/18
_____Note taker
_____Extended Time for testing
_____Alternate Testing site
_____Adaptive Equipment (E-books or books on CD)
_____Excused Tardiness (15 minutes)
_____Assistive Technology _____________ (specify)
_____Scribe
_____Digital recorded lectures
_____Enlarged print
_____Emergency Note taker
_____Preferential Seating
_____Use of laptop or calculator
_____Accessible tables/desks/chairs
_____Other _____________________
