request_for_services

SERVICES FOR STUDENTS WITH DISABILITIES
REQUEST FOR SERVICES FORM

Completion of this form is voluntary. However, UNMC requests that this document be completed for persons seeking accommodation in order to ensure meaningful evaluation and appropriate accommodation consistent with reliable and useful medical information.

GENERAL INFORMATION Date_____________________________

Student Name_____________________________________________________________________________________

Birth date______________________ Social Security#_________/_________/_________

Mailing Address__________________________________________________

Home or Cell Phone_______________________________________

City________________________________State__________Zip___________

Wk Phone_________________________

Campus mail box __________________________________________

ADMISSIONS INFORMATION

Enrollment status

______ Currently enrolled student at UNMC ______ Accepted for enrollment

______ Application for admission pending ______ Other

Semester for which student is initially seeking services

______ Fall ______Spring ______ Summer Academic year 19_______-19________

Projected graduation date___________________

Advisor's Name_________________________________________________

Advisor's Campus Address_________________________________________

ADMISSIONS INFORMATION (CONT)

COLLEGE OR PROGRAM CLASS (Circle one)

______ Medicine M1 M2 M3 M4

______ Pharmacy P1 P2 P3 P4

______ Nursing
                Omaha                           NS1    NS2    NS3    NS4    NS5    NRN
                Lincoln                          US1    US2    US3    US4    US5    URN
                Kearney                         KS1    KS2   KS3    KS4    KS5    KRN
                Scottsbluff                   WS1    WS2 WS3   WS4   KS5    WSN

______ Dentistry D1 D2 D3 D4 Grad
______ Dental Hygiene DH3 DH4

Allied Health Professions

______ Physician Assistant PA3 PA4 PA5

______ Physical Therapy PT3 PT4 PT5

______ Medical Technology 4

______ Radiography 2 3 4

______ Radiation Therapy Technology 4

______ Diagnostic Medical Sonography 4

______ Nuclear Med Technology 2 3 4

______ Medical Nutrition 5

______ Cytotechnology 5

______ Clinical Perfusion 5 6

Graduate College

______Program____________________________________________________________________________________

Anticipated graduation date_________________________ Degree anticipated___________________________________

DISABILITY INFORMATION (check those which apply)

______ vision ______ hearing ______ speech ______ mobility ______medical ______psychological

______ learning ______ other_________________________________________________________________________

Post-secondary institutions at which you previously received accommodations: Dates/ from-to

___________________________________________________________________ _______________________

Describe accommodations received at previous post-secondary institutions.

_________________________________________________________________________________________________

Have you ever received services from VOC REHAB? ____ Y____ N Dates from______________ to_______________

Voc Rehab Counselor__________________________________________________________________________________________

Address___________________________________________________________________________________________

City___________________________________________State_________ Zip__________ Phone(______)____________

Person from whom we may expect MEDICAL documentation of your disability.

Name_____________________________________________________Title____________________________________

Address__________________________________________________________________________________________

City________________________________________State_________ Zip__________ Phone(______)_______________

Description of disability______________________________________________________________________________

________________________________________________________________________________________________

CLASSROOM ACCOMMODATIONS TO FACILITATE ACADEMIC GOALS

Testing Accommodations

______ All exams including pop quizzes

______ Separate, quiet exam room

______ Extended time ___ LD - 150% ___ ADD - 120%

______ Proctor to read test questions

______ Proctor to assist with scantron answer sheets

______ Sign Language Interpreter

______ Tape recorder

______ Large print

______ Braille

______ Other ____________________________________________________________________

____________________________________________________________________

______ Assistance with Note Taking

______ Audio Tape Classroom Lectures

______ Media Accommodations

Difficult Media Media Accommodations

______ Fine print ____________________________________________

______ Ditto copies ____________________________________________

______ Chalkboard ____________________________________________

______ Overhead projector ____________________________________________

______ Transparency ____________________________________________

______ Text book ___________________________________________

______ Other ___________________________________________________________

________________________________________________________________________________________________

CLASSROOM ACCOMMODATIONS (CONT)

Facility Accommodations

______ Accessible Classroom

______ Table height _____ Chair _____ Stool _____ Podium

______ Other_____________________________________________________________________________________

________________________________________________________________________________________________

______ Other Accommodations (describe)

________________________________________________________________________________________________

REQUEST FOR ACCOMMODATION

Based upon diagnostic documentation reasonably requested by the University of Nebraska Medical Center, which I agree to supply, I hereby request the accommodation described above. I understand that this request must be submitted in order that the Coordinator is provided a reasonable amount of time to evaluate and arrange for any accommodation indicated. Should I fail to submit this in a timely manner, I understand that I may not receive my accommodation at the time I desire.

__________________________________________________________________ _____________________________
Student Signature Date

SERVICES FOR STUDENTS WITH DISABILITIES

RELEASE OF INFORMATION

I, ____________________________________________, SSN_______________

hereby authorize the Coordinator of Services for Students with Disabilities to consult and/or share information regarding my disability and/or accommodation request with such persons that have reasonable need to know for the purpose of arranging and evaluating the need for accommodations during my enrollment at the University of Nebraska Medical Center:

I understand that this permission may be revoked by submitting such revocation in writing to the Coordinator, Services for Students with Disabilities.

_________________________________________________
Signature Date

_________________________________________________
Witness Date