Christian Brothers University Student Accessibility & Accommodations Request

Students can submit a request for special accommodations.

STUDENT CONTACT INFORMATION
Name Name * First Last
899 Student ID: (Form will NOT be processed without your valid 899 ID number) *
Classification *

Classification Freshman Sophomore Junior Senior Graduate Student
Christian Brothers University Email ONLY: (Other email addresses will not be communicated with) *
Phone: (Please provide a working phone number to directly reach the student) Phone: (Please provide a working phone number to directly reach the student) * - ### - ### ####
Which term are you requesting an accommodation for? *

Which term are you requesting an accommodation for? Fall Spring (Disability Accommodations granted for the Spring semester carries into the Summer sessions also)
Semester year you are requesting accommodations:

Provide the semester year for which you are requesting accommodations (ie: 2024)
When is the last time you were granted Accommodations at CBU?

When is the last time you were granted Accommodations at CBU? This is my first time requesting Accommodations at CBU I received Accommodations last semester I am not sure
DISABILITY INFORMATION

All disability information is encrypted for security and confidentiality purposes.
What is your disability or disabilities? *

What is your disability or disabilities? Learning Disability ADD/ADHD Traumatic Brain Injury Language Delay Hearing Impairment Visual Impairment Physical Disability Other Other

Please check all that apply.
Please provide a brief description of the physical or mental disability you have been FORMALLY diagnosed with. (If you have not been officially diagnosed by a licensed medical professional, please do not self-diagnose; your request will be DENIED). *
Please describe your experiences in the following settings.
What academic challenges do you experience or have you experienced in the classroom because of your disability? (This is ONLY to help gauge what resources you may need and to ascertain if CBU can adequately provide it) *
What specific accommodations are you requesting? (Please know that all requested accommodations may not be available or offered by the University)
You are aware that you must provide current legitimate MEDICAL documentation of your disability from a certified licensed medical professional?

*Note: All documentation must be up-to-date and can be no older than four (4) years. Also, IEPs, records from High School and letters from unlicensed medical professionals will NOT suffice for medical documentation. *

You are aware that you must provide current legitimate MEDICAL documentation of your disability from a certified licensed medical professional?

*Note: All documentation must be up-to-date and can be no older than four (4) years. Also, IEPs, records from High School and letters from unlicensed medical professionals will NOT suffice for medical documentation. Yes
POTENTIAL ACCOMMODATIONS

**Please be aware that requesting specific accommodations does not guarantee that it will be granted to you and that CBU may not be able to offer all requested accommodations listed below.
Draw your signature into the box below for verification. *

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Christian Brothers University Student Accessibility & Accommodations Request

Christian Brothers University Student Accessibility & Accommodations Request

STUDENT CONTACT INFORMATION

DISABILITY INFORMATION

POTENTIAL ACCOMMODATIONS