ADA Form

PENN FOSTER CONFIDENTIAL STUDENT REQUEST FOR ACCOMMODATION UNDER THE AMERICANS WITH DISABILITIES ACT (ADA)

Individual Requesting Accommodation:

Penn Foster Student ID Number:

Current Penn Foster Program:

Phone Number

Area CodePhone Number

Email:

example@example.com

Important Note: In order for your request to be processed, documentation from a medical/healthcare professional or IEP, issued within 5 years of today's date and signed by a professional is required to be provided.*
Penn Foster is a private institution and doesn’t provide or develop IEPs.

*Additional Information is required on the next page

ACCOMMODATION REQUESTED: (please specify the accommodation that you’re requesting)

REASON FOR ACCOMMODATION: (please specify the condition or limitation for which you see)

HEALTHCARE PROVIDER INFORMATION

1. Please provide where indicated below the name and contact information for your medical/healthcare professional.

2. Please attach documentation provided by your medical/healthcare professional describing your condition or limitation that prompts this request for accommodation.

3. Please ensure that this documentation is on the letterhead of your medical/healthcare professional or treating hospital or clinic and signed by your medical/healthcare professional.

Please provide where indicated below the name and contact information for your treating physician and attach any documentation provided by your physician describing your condition or limitation that prompts this request for accommodation. Please ensure that this documentation is on the letterhead of your physician or treating hospital or clinic and signed by your physician.

Attending Healthcare Provider’s Name:

Attending Healthcare Provider’s Specialty:

Address:

City:

State:

Zip:

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Documentation may be faxed to 570.961.4642 or e-mailed to ADArequest@pennfoster.edu

Individualized Educational Plan (IEP):

(Must be issued within 5 years of the current date)

1. Please provide where indicated below the name and contact information of the School/Organization who developed your IEP.

2. Please attach documentation provided by your previous school/organization describing your condition or limitation that prompts this request for accommodation.

3. IEP must be signed by an official of the issuing school.

4. Date IEP was issued or last evaluation date.

IEP Developer's Name;

First NameLast Name

School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number

Area CodePhone Number

STUDENT SIGNATURE:

Clear

DATE:

Date

CONFIDENTIALITY

All medical-related information shall be kept confidential. However, supervisors and managers may be advised of information necessary to make the determinations they’re required to make in connection with your request for an accommodation. Government officials investigating compliance with the ADA and the ADAAA may also be provided relevant information as requested.

All completed requests for accommodation will be reviewed by the ADA Review Committee within five (5) business days. Students will receive an email that outlines what accommodations (if any) have been approved, and the process for delivering the approved accommodations.

Your request should be returned to Penn Foster by fax 570.961.4642 or by email addressed to ADArequest@pennfoster.edu