Accommodation Request Form

Student Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Name

Pronouns

Student F Number

Institution Email Address

Please use your university issued email address

Personal Email Address

Mobile Phone Number

Other Phone Number

Date of Birth

Current student status?

Intended Major

Anticipated Graduation Date

Are you currently on academic probation?

Are you a veteran?

Are you a client of the Division of Rehabilitation Services?

Are you in the AIMSS progam?

Specific Accommodation Information

Please submit your completed registration form below.

Completion of this form alone does not warrant accommodations. Through individual consultation we engage in an interactive process with each student to understand how his or her disability intersects with the institutional environment, and how accommodations would reduce barriers while not fundamentally altering essential components of the course, program, activity, or experience. Essential functions, tasks, standards, and requirements of each class, major, or program cannot be removed or waived. If you are not contacted within 2-3 business days, please call 304-367-4543 to schedule an intake. As mentioned above, there are times when we experience intermittent delays in email correspondence, so this will ensure prompt attention to your request for services. Thank you!

Diagnosis

Please describe your disability and how it affects you as a student.

(i.e. reading, writing, concentration, memory, time management)

Please describe any accommodations you had in the past.

Which of the following tasks do you find easy?

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Which of the following tasks do you find difficult?

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Please describe any physical access assistance that you may require.

Please list and/or describe the academic accommodations you are requesting.

Please describe any housing accommodations you are requesting.

Students requesting housing accommodations also need to complete a Housing Application, which can be found by logging onto myFairmontState and clicking on the housing icon.

Please include additional information you would like to share.

Acknowledgments

Please review and check each box indicating you agree with each statement.

By submitting this application, I understand that to receive accommodations I must upload, fax to 304-367-4584, email to access@fairmontstate.edu, or bring documentation to 303-O Turley Center. By submitting this application, I understand that this information will be treated as confidential and used only for the purpose of determining eligibility, providing academic or other accommodations, and the administration of accommodative services. By submitting this application, I understand that the Office of Accessibility Services will contact me to schedule an appointment and that I must schedule an appointment prior to the approval of any accommodations. By submitting this application, I understand that I must participate in the accommodation process by requesting accommodations each semester and communicating any difficulties I may be having in obtaining an authorized accommodation. By submitting this application, I understand that accommodations are not intended to alter standards or content of any course and/or degree program.

Upload supporting document(s)

The student's disability must be diagnosed by a qualified professional and include a clear statement of the diagnosis. Documentation should be no more than 3 years old. The documentation should include the student's needs, the impact the disability has on the student, and recommendations for reasonable accommodations. Appropriate documentation may be one of the following: a letter from a health care provider that is typed, on letterhead, and recently dated; Neuropsychological, psychoeducational, and medical evaluations; or Audiograms, eye exams, etc. Further information can be found on the Office of Accessibility Services webpage.

Accommodation Request Form

Student Information

Specific Accommodation Information

Document Information