Office of Student Disabilities Services
3702 Spruce Street (Stouffer Commons), Ste 300
215-573-9235 (Voice), 215-746-6320 (TDD), 215-746-6326 (Fax)
http://www.vpul.upenn.edu/lrc/sds
e-mail:
STATEMENT OF AGREEMENT
A resource assistant plays an important role in the academic success of a student with a disability. This agreement is to be signed by the resource assistant and student/recipient and placed on file with the Office of Student Disabilities Services (SDS). This form is designed to obtain information and to set forth guidelines for both resource assistant and student. It is the mutual responsibility of both parties to make the appropriate adjustments so that each person benefits from these arrangements.
RESOURCE ASSISTANT
Name LOCAL Address
Social Security Number LOCAL Telephone Number E-mail Address
School and Class
PERMANENT Telephone Number PERMANENT Address
STUDENT
Name LOCAL Address
Social Security Number LOCAL Telephone Number E-mail Address
School and Class
PERMANENT Telephone Number PERMANENT Address
AGREEMENT
The resource assistant will provide _____ hours per week for _____ weeks during the (circle one) Spring/Fall/Summer Session 20___ in the following courses:
This agreement may not be modified during the semester without consulting the SDS. Additional hours must be approved by SDS. Both parties should follow this schedule to the best of their ability, barring unforseen circumstances.
The resource assistant and student will maintain a weekly schedule as follows:
Subject Days Time
The resource assistant may consult with the student’s professor(s) who are listed below if the need arises and only with the consent of the student:
The student will evaluate the resource assistant for punctuality, reliability, quality of services, and will advise the SDS in the event of unsatisfactory services.
If the resource assistant is a notetaker, class attendance is required of the student (Notetaking services is NOT a surrogate service). If the student will not be able to attend class, the student must notify the notetaker immediately stating he/she will not be in class. Notetaking is not required of the resource assistant if the student is not in class.
The resource assistant must notify the student ASAP if he/she will not be able to attend a class. In that event, the student should notify SDS and SDS will attempt to get a replacement notetaker. Comments and/or suggestions from the students and resource assistants are appreciated.
The payment for the sessions provided herein is ________ per hour for _____hours for _____weeks. The total amount permitted for this semester is _________________.
Resource Assistant Log Sheets must be properly filled out, signed by both the student and resource assistant, and submitted to SDS weekly by 5:00pm Wednesday.
The Resource Assistant understands that the service he/she provides involves confidential disability information. Any and all information regarding the service he/she provides as it pertains to the student serviced, his/her identity and his/her disability must be held in the strictest of confidence. Breach of confidentiality will result in immediate termination and possible further action by the Office of Student Disabilities Services.
I have read the above and agree to the conditions specified. Furthermore, I understand that this agreement may be terminated if either the resource assistant or student is dissatisfied and either party so notifies SDS in writing.
Resource Assistant Signature Student Signature
Date Date 8/04