Disability Services - Accommodation Request Form
Step 1 of 2: Submit
Name
*
Student ID Number
*
Phone
*
PSC Student Email
*
Please complete this information for every course you are registered for and requesting accommodations; incomplete or inaccurate information may delay the process.
Semester
*
Fall
Spring
Summer
Class 1
Course Code & Section Number
*
I am requesting the following accommodations for this course*
*
Class 2
Course Code & Section Number
I am requesting the following accommodations for this course
Class 3
Course Code & Section Number
I am requesting the following accommodations for this course
Class 4
Course Code & Section Number
I am requesting the following accommodations for this course
Class 5
Course Code & Section Number
I am requesting the following accommodations for this course
Class 6
Course Code & Section Number
I am requesting the following accommodations for this course
I have had an intake session with the Office of Disability Services.
*
Select an option:
Yes
No
I have submitted my documentation.
*
Select an option:
Yes
No
I have completed the Disability Services Intake Form
*
Select an option:
Yes
No
Please note:
-Accommodations are processed on a first-come, first-served basis. Some accommodations may take up to 4 weeks to arrange.
- If you make changes to your schedule, you
must
complete a new form.
- If you are requesting changes to your existing accommodations, you
must
complete a new form.
- Accommodations are not retroactive. Approved accommodations will be effective from the date of the accommodation approval.
- Instructors will receive an accommodation letter, detailing
approved
accommodations via email by the Office of Disability Services.
By submitting this form, you certify that you are the student named above, requesting accommodations from the Prairie State College, Office of Disability Services.
To certify your responses, review your input and provide an electronic signature (sign your name)
*
Date:
Wednesday, 9 October 2024 (EDT)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
Scan this QR code with your phone:
*
indicates required fields