New Accommodation Request

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Kutztown University Disability Services Office (DSO)

This information will be kept strictly confidential and will enable us to advise you of available support services.
Please use your university issued email address
Are you a vet or currently serving in the military?

Disability Impact and Accommodation Requests

Describe how your disability or disabilities currently impact(s) you in the following settings.
Enter “none” if there is no impact in this setting.
Enter “none” if there is no impact in this setting.
Enter “none” if there is no impact in this setting.
What accommodations are you requesting?
Enter “none” if no accommodations are needed in that area.
Specify below: i.e., preferential or accessible seating, note taking assistance.
Specify below: i.e., alternative textbook format, use of electronic or enlarged print handouts/materials.
Specify below: i.e., extended test time, distraction reduced testing, scribe, reader.
Specify below: ASL interpreter, FM system, captioning.
Specify below: special room arrangements, special dietary needs.

Academic History

If you are requesting housing or dining accommodations only, you may skip questions 1-12 below and go directly to the Disclosure Statement at the end of this document.

1. Did you have an IEP while in highschool?
2. Did you have a 504 Plan/Agreement while in high school?
3. Did you have accommodations at another college or university?
7. Did you have a one-on-one aid or classroom assistant while in high school?
8. Did you have the ability to re-take exams (due to low grades) while in high school?
9. Did you receive teacher’s notes or guided notes while in high school?
10. Did you take modified exams (i.e., have fewer questions/responses) while in high school?
11. Did you have modified homework assignments while in high school?
12. Did you use electronic textbooks or audio books while in high school?

Disclosure Statement

I understand that in the process of arranging for specific accommodations, the DSO may need to disclose limited information about me to other campus personnel. The information disclosed will not be more than is necessary to process the request.

All communication regarding the status of this request will be sent to the student’s KU email account. Please check this account frequently for updates and further instructions.

  
Upload supporting document(s)

Documentation Guidelines for Academic Accommodations:

Submission of documentation based on the guidelines found on our website:

Submit a copy of your most recent 504 Plan or IEP and Evaluation/Re-Evaluation Report from high school including:

· aptitude/cognitive functioning and achievement test scores

· any information about information processing/cognitive abilities including speed of processing, cognitive efficiency, visual-auditory processing, perceptual-motor processing, executive functioning including memory, concentration, and attention and language abilities including expressive-receptive language and speech.

If you were diagnosed by a private evaluator (i.e., outside the school setting) submit a copy of the evaluation report in which your diagnosis was made, as well as the most recent 504 Plan or IEP and Evaluation/Re-Evaluation report from your high school.

Submit a letter from your treating physician/specialist that includes:

o a statement of diagnosis

o description of the symptoms/impact

o current treatment methods

o description and impact of the diagnosis on your ability to function in the college environment

o any care provider recommendations for accommodations.

Please Note: All documentation must be typewritten on letterhead, dated, and signed by an evaluator who has the training and appropriate licensure to conduct evaluations and render diagnosis. The documentation must be recent and include the name, title, professional credentials, and contact information of the evaluator.

If applicable, you may also submit a copy of your most recent 504 Plan or IEP and most recent Evaluation/Re-Evaluation Report from high school. Documentation can be submitted via this link, or sent to the Disability Services Office directly via email at DSO@kutztown.edu; or via fax at 610-683-1520.

Kutztown University does not discriminate in employment or educational opportunities on the basis of sex, race, ethnicity, national origin, age, disability, religion, sexual orientation, gender identity, or veteran status. To discuss a complain of discrimination, please contact the University’s Title IX Coordinator located in the Office of Social Equity, Old Main A-Wing, Room 02, by phone at 610-683-4700 or by email at pena@kutztown.edu or the Office for Civil Rights located in the Lyndon Baines Johnson Department of Education Building, 400 Maryland Avenue, SW, Washington, DC 20202-1100, by phone at 800-421-3481 (TDD: 800-877-8339), by fax at 202-453-6012, or by email at OCR@ed.gov

Kutztown University Disability Services Office (DSO) contact information: Voice: (610) 683-4108

TTY: (610) 683-4499

FAX: (610) 683-1520

Email: DSO@kutztown.edu

Website: www.kutztown.edu/DSO