Disability Form

This form serves the purpose of informing the Director of Accessibility Services of your specific disability and explanation of what is needed in order to help you be successful at Benedictine College with the assistance of reasonable accommodations.

First Name

Last Name

Benedictine Email Address

Birthdate

What is your diagnosis or diagnoses?

Please explain other:

What accommodations are you requesting?
Please be specific and describe your current accommodations.

If you are receiving additional support, in what subjects?

How will the above accommodations eliminate your academic barriers and help you to be successful at Benedictine?

Any other disability information you would like to share?

Documentation for Reasonable Learning Accommodations
1. High School IEP (will be considered, but may not be sufficient documentation)
2. High School 504 Plan (will be considered, but may not be sufficient documentation)
3. Psychological Evaluation by a licensed therapist
4. Doctor’s Evaluation (on letterhead)
5. Specific Learning Disability Evaluation
6. Other
Documentation Criteria
1. A diagnosis of your current disability
2. Date of the diagnosis
3. How that diagnosis was reached
4. The credentials of the diagnosing professional
5. Information on how your disability affects a major life activity
6. Information on how the disability affects your academic performance
7. Professional’s recommendations for reasonable learning accommodations or services (optional)

If you have an IEP/504 Plan, when was your last update with additional testing?

Please send documentation to Jennifer DuLac