Request for Accommodations

This request is for (check any that apply) -

Academic Accommodations for Classes Accommodations involving Housing, the Dining Hall or on/off campus events sponsored by the university
This request is for (you may only select one per submission):

Academic Accommodations for Classes Accommodations involving Housing, the Dining Hall or on/off campus events sponsored by the university

Course Schedule *

	CRN	Course Prefix (BIOL, MATH, ENGL, etc)	Course Number & Section	Faculty's Name	Want accommodations for this class? (YES/NO)	Notify faculty you have accommodations? (YES/NO)
Course 1
Course 2
Course 3
Course 4
Course 5
Course 6
Course 7
Course 8

Type of Request *

Initial/First Time Request - I am requesting (or making a pre-request for) accommodations at WVSU for the first time Returning Student - Applying for previously WVSU approved accommodations for the current/next semester. Returning Student - I have previously had accommodations at WVSU and am applying for new/additional accommodations

Description of Disability, It's Impacts and Challenges You May Face in the College Environment
Please describe how your disability affects/will affect your daily life and overall school experience; what are the signs and symptoms and what challenges do you anticipate will be, or are, present when they interact with the college environment: *
Are you requesting accommodations for academics in the classes in which you will be registered? *

YES NO
Think about the requirements for classes and the work you will be expected to do. You may want to look at class syllabi or other resources to help you think about these things. For example, does the professor primarily use lectures? Will students be interacting during the class? Are videos a part of the course? Will there be projects or reports? How much reading is required? Are the tests open-ended, multiple choice or other formats? Describe any course related expectations that might be a challenge for you and what accommodations you could use to meet these challenges better.
Do you have any concerns about the social expectations of college (for example, asking questions in class, working with fellow students in groups, making presentations before a group, participating in group discussions, getting along with students/faculty/staff, etc.)? *

YES NO
For some students, working with others can be a challenge, while for others, having a study partner or working on a team brings out their best. For the courses and major you are thinking about, or are, pursuing, what are the social requirements? Does the instructor expect you to participate in class discussions? Are there small group discussions? Team Projects? Will students have partners (for example, a lab partner)? Will you be making presentations in class or before a group? Describe any social expectations that might be a challenge for you and what accommodations you could use to meet these challenges better.

Approved Accommodation Requests

If you have previously been approved for any of these accommodations, you may make the request to utilize these accommodations for the upcoming/current semester here.
Type of Accommodation Request

Digital Textbooks Digital Note Taking Services / Peer Note Taker

Submission Page
By submitting this form and typing my name below, I affirm that I -
- am a student at West Virginia State University
- have personally completed this form in it's entirety
- have provided accurate and complete information regarding myself
Name

First Name Last Name
Student's Name
Should be Empty:

	YES	NO
Did you have an IEP or 504 plan in middle or high school?
Have you seen a diagnosing and/or treatment professional for your impairment in the last five years?
Have you had an evaluation for your impairment within the last five years?
Are you currently a client of the WV Division of Rehabilitation Services or comparable agency in your home state?

	YES	NO
I understand I must allow 2 weeks to obtain digital textbooks because they are dependent on publisher's approval and availability.
I understand although I may prefer one format over another, SAR does not have control as to which format will be available from the publisher.
I understand there may be times when some text will not be available in an electronic/alternative format and that I must allow a reasonable time frame in order for SAR to request permission from the publisher and produce an alternative textbook version.
I understand that I must provide proof of possession of the textbook before a digital/alternative textbook can be provided.
I understand all digital/alternative textbooks must be returned to SAR by the last day of the semester and that if I fail to do so, a hold will be placed on my account. This hold will not be removed until I have returned the digital/alternative textbook in the same condition as I received it.

	Course and CRN/Section	Textbook Title	ISBN	Textbook Year
Textbook 1
Textbook 2
Textbook 3
Textbook 4
Textbook 5
Textbook 6
Textbook 7

	YES	NO
I understand that I must submit requests for testing with SAR at least 3 business days in advance of the test.
I understand that I will be scheduled at the SAR Testing Center according to availability of space.
I understand that all tests are to be taken at the same time the class is scheduled to take the exam unless I have the approval of the faculty to test at another time.
I understand that all testing rooms are monitored by video and in-person.
I understand no electronic devices, books, notes or other aids are allowed in the testing room without the consent of the faculty.
I understand my belongings will be locked in the SAR Testing Center closet before I enter the testing room and returned once I complete and return the test to SAR staff.

	Class	Faculty Name	Date Exam Scheduled	Time Exam Scheduled
Test 1
Test 2
Test 3
Test 4
Test 5
Test 6
Test 7
Test 8
Test 9
Test 10

Request for Accommodations

Temporary Conditions

Types of Accommodations

Condition and Documentation

Current Issues - Indicate if any of the below are current issues for you

Description of Disability, It's Impacts and Challenges You May Face in the College Environment

Accommodations

Approved Accommodation Requests

Digital/Electronic/Alternative Textbook Request

Note Taking Accommodations

Current Issues

Submission Page

	YES	NO
I understand that the faculty will receive notification from the SAR and that it is also my responsibility to contact each faculty member before using a recording device to inform him/her that a device will be used in class.
I understand that information contained in the recorded lecture is protected under federal copyright laws and may not be published without the consent of the lecturer.
I agree that I will not share, send, post publish, make public, or duplicate any recordings without the written authorization of the recorded person(s).
I understand that failure to abide by these rules may render me liable to the faculty member and members of the class for breach of privacy and violation of copyright laws.
If using a recording device for note-taking, I agree that recording classes is permissible solely to facilitate my note-taking accommodation and for no other purpose.
I agree to destroy my recording of any classes at the end of the semester. If my recording is for a class that I need to refer to in the future, I agree to destroy my recording at the completion of any courses that are dependent on this course.
I understand that failure to abide by these rules is considered a serious violation of West Virginia State University standards and subject to disciplinary action.

	YES	NO
Do you want your identity to remain anonymous/confidential from the peer note taker?
I understand that if I am requesting that my identity remain anonymous/confidential, it may take longer to identify and obtain a note taker.