Banacos Academic Center

Disability Services

413-572-5789 v

Reasonable Accommodations Request

Complete this form for each semester you need classroom accommodations.

Accommodations may take up to two weeks to get into place (most classroom accommodations). Others may take longer or require advance notice (i.e., housing alterations, early course registration, interpreters, note takers). Please submit your request in a timely fashion.

Today’s Date: ______

Request for: Full academic year: ______(i.e., 2014-2015) OR

Semester: ______(i.e. fall 2014, summer 2015, etc.)

Name: ______UWID#: A______

Address: ______

Phone: ______Email:

Major 1: ______Major 2: ______

What accommodations are you requesting? Include all housing, classroom, parking, dining, and other accommodations you may need. Be specific (i.e. extended time for exams, first floor housing, residential hall with elevator, etc.)

If you are requesting exam accommodations please check all that apply:

o 50% (time and a half)

o 100 % (double time)

o Reduced distraction environment

o Reader

o Scribe


Accommodation Notices

Send to all instructors:

____ I would like all of my instructors to receive a notice of accommodation.

Send for only some courses:

Please write in the courses and instructor names. Please check whether the instructor should receive information about you having a disability.

Course &
Section Number
(i.e., ENGL 0102-001) / Instructor / Instructor to receive notice? Check One
1.  / o Yes o No
2.  / o Yes o No
3.  / o Yes o No
4.  / o Yes o No
5.  / o Yes o No

*If your schedule changes after you have submitted your request, be sure to inform your Banacos advisor.*

Which offices would you like notified and what should we tell them?

o  Residence Life ______

o  Facilities ______

o  Parking Clerk ______

o  Dining ______

o  Registrar______

o  Other: ______

Is there any other information you would like us to share with other offices or instructors?

oNo

oYes. What information and to whom?

______

Student Signature Date

If submitting this form electronically, type in your name and the date above and send it from your Westfield State email address.