ACCOMMODATIONS REQUEST FORM                   

Office Use Only – Office Use Only

 

(Director’s / Specialist’s Signature)

Date: _____________________

  



1.) TODAY’S DATE________________________

2.) NAME_____________________________________________________________
                  First                                                Middle                                       Last

3.) HOME ADDRESS____________________________________________________
                                                          Street
     ___________________________________________________________________
                        City                              State                            Zip Code

4.) CAMPUS ADDRESS______________________________________________________________________________________

5.) PHONE______________________ CAMPUS _______________________CELL______________________________________

6.) USM E-MAIL____________________________________________________________
                                                                                                                       Expected Graduation ____________ Major­­­_________________
7.) STUDENT ID # _________________________________ 8.)Circle One: Fr  Soph Jr Sr Grad Law Non-matric  9.)Circle One: Part / Full Time

 

Accommodation Form 2009 

 

 

16.) WAIVER STATEMENT:  I give permission for the Office of Support for Students with Disabilities to provide information & recommendations which will help in providing reasonable accommodations for me.
                                                                                 Signed_________________________________________________________________________
OSSD, USM, 242 Luther Bonney Hall, Portland, Maine 04104-9300  Tel. (207) 780-4706, TTY (207) 780-4395,  Fax (207) 780-4403

 

 

 

 

 

 

 

 

INSTRUCTIONS FOR COMPLETING ACCOMMODATIONS REQUEST FORM
(An incomplete form will be returned for completion)

1-9.     Enter all of the information requested in this section.

    1. List ALL of the courses that you are taking for the desired semester.

 List all courses whether on not you require accommodations for all of those classes. 

  1. Write the Class for the course (I.E., LEC  20429)  Note the changes this semester because of Maine Street

 

  1. Write the Catalogue number. (I.E., BIO 101)  Note the changes this semester because of Maine Street
  1. Write the course title.  (I.E., Biological Foundations)

 

  1. Write the amount of credit hours for the course. (I.E., .5, 1, 2, 3, 4)

Write the days and time the course meets.  (I.E., M/W 8:30-10:15am)

  1. Write the Building and room number where the course meets. (I.E., Luther Bonney 326)

Write the FULL name of the professor.  (I.E., Thomas A. Martin, there are many professors with the same last name)

  1. Write the accommodations you are currently requesting for each course, on the same line as the course information. 

If you are not requesting accommodations for a particular class write the word NONE. 
If you are requesting accommodations that have not been approved in the past, call to schedule a phone or office appointment
with either Joyce Branaman or Bill Ferreira to discuss your request.  Tel. 780-4706; TTY 780-4395

  1. Sign the form beneath the waiver statement.