Banacos Academic Center

Disability Services

ds@westfield.ma.edu

Reasonable Accommodations Request

Disability Services

This form is to be filled out and submitted by the student only.

Today's Date	*
Length of Request:	*	Full academic year One semester or session
What year, semester or session? (i.e. 2020-2021, Fall 2020, or Summer I)	*
Last Name	*
First Name	*
Address	*
Cell Phone Number	*
Cell phone provider (AT&T, Verizon, etc.)	*
WSU email address	* a copy of the completed form will be sent here.
Major 1:	*
Major 2:
What academic accommodations are you requesting? Select all that apply	* **If you select the first box you don#039;t need to select any other boxes. You can then skip to the next section. ***If you want to add a new accommodation, you may also select any additional boxes for new requests.	I am not requesting academic accommodations I want to request the same academic accommodations I had at WSU last semester. 50% (time and a half) for exams 100% (double time) for exams Reduced distraction environment for exams Calculator for exams Reader for exams Scribe for exams Use of computer for exams Allow backtracking on exams Unlimited printing E-text Note taking assistance Classroom (i.e. allowance for breaks, furniture). Please explain in box below.
What other accommodations are you requesting? **If you select any of these, please explain what you are looking for in the box below		Housing (i.e. single in suite, residential hall with elevator) Parking Dining Other
Accommodation Notices	*	I am not requesting academic accommodations Send to all instructors: I would like all of my instructors to receive a notice of accommodations Send for only some course: I will list the course I want to receive my accommodation notice below
**If you selected only some courses above: Please write in the courses and instructors names to whom we should send a notice of accommodation.
Do you need assistance during an emergency evacuation?	*	No Yes **Please explain in the box below
Which offices would you like notified and what should we tell them?
Residential Life
Facilities
Parking Clerk
Dining
Registrar
Other
Is there any other information you would like us to share with other offices or instructors?	*	No Yes
If yes, what information and to whom?