CBU Student Accessibility Accommodation Request

Students can submit a request for special accommodations via the Student Accessibility Accommodation Request MachForm.

STUDENT CONTACT INFORMATION
First Name *
Last Name *
Banner ID: (Form cannot be processed without your ID number) *
Classification *

Classification Freshman Sophomore Junior Senior
CBU Email: *
Student Phone: Student Phone: * - ### - ### ####
Which term are you requesting an accommodation for? *

Which term are you requesting an accommodation for? Fall Spring
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. *
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? *
What other types of support do you think you may need to help you be successful in the academic environment?

*Note: (Some accommodations you request may not necessarily be available) *
POTENTIAL ACCOMMODATIONS

All accommodation information is encrypted for security and confidentiality purposes.
**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.
What accommodations are you requesting? *

What accommodations are you requesting? Extended Testing Time Low-Stimuli Testing Environment Lecture Recording Alternative Test Format Note Taking Services Hearing Interpreter Services Other Other

Please check all that apply.
What accommodations, if any, have you used in the past? *
You are aware that you must provide current legitimate documentation of your disability from a certified medical professional?

*Note: All documentation must be up-to-date and can be no older than four (4) years. *

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

*Note: All documentation must be up-to-date and can be no older than four (4) years. Yes
Draw your signature into the box below for verification. *

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CBU Student Accessibility Accommodation Request

CBU Student Accessibility Accommodation Request

STUDENT CONTACT INFORMATION

DISABILITY INFORMATION

POTENTIAL ACCOMMODATIONS