Request for Accommodations: Self-Disclosure Form

Request for Accommodations: Self Disclosure Form

Any information received from outside parties is used exclusively for the purpose of determining on-campus accommodations. It will be kept in a secure location, and will not be released except in accordance with state and federal law.

New Student Intro Survey

Today's Date

Last Name

First Name

Enrolled at:

	College of St. Benedict
	Saint John's University

Banner ID Number

Cell Phone Number

Provide a brief description of your disability/condition:

Describe how your disability/condition impacts your ability to learn:

List and describe the academic accommodations you are requesting:

List and describe any auxiliary aids, assistive technology and/or services that you anticipate using as a student at CSB/SJU (i.e. PCA, FM system, wheelchair, adaptive technology, etc.):

Submission of Documentation

While your input will be taken into consideration, diagnostic documentation from an outside professional is often essential to confirm the appropriateness of academic accommodations. If you do not have documentation, we encourage that you print out our "Documentation of Disability Form" and have it completed by your provider.

If you are unable to provide documentation, you are still highly encouraged to complete this form and schedule an appointment.

Documentation

Delivery of Documentation

	My documentation will be uploaded as an attachment to this form (below).
	My documentation will be mailed to the Disability Services Office.
	My documentation will be faxed to the Disability Services Office.
	My documentation will be mailed to the Disability Services Office.
	I will hand deliver my documentation to the Disability Services Office.
	I do not have documentation. I would like to discuss this during my meeting with the Disabiltiy Specialist.

Upload Disability Documentation Here:

Personal Affirmation:

I affirm that the information provided in this form is true and accurate. I understand that submitting this form is just the first step in receiving an accommodations plan at CSB/SJU. Completing this form does not guarantee the provision of accommodations. My next steps should include:

1. Submitting Documentation: As mentiond above, in most cases documentation is necessary to validate an accommodations plan. If you have documentation that was not uploaded to this form, it can be sent to one of the following:

US Mail: CSB/SJU Disability Services

CSB ASB 212

37 South College Avenue

St. Joseph MN 56374

FAX: 320-363-5600

Email: [email protected]

2. Schedule an intake meeting: Call to set up a meeting with Tom Sagerhorn, Disability Specialist. Determining accommodations is an interactive process in which your input is essential. During this meeting you will have the opportunity to collaborate as a team to develop a plan to fit your needs and abilities. To schedule an appointment call the following number: 320-363-5687.

Confirmation

Online Signature

Date

Request for Accommodations: Self-Disclosure Form

College of Saint Benedict

Saint John’s University