Student Accommodation Request

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Please review the following information before completing this form.

Welcome to SAS! Student Accessibility Services (SAS) works collaboratively with students, faculty, and staff to enable equal access to education and university life for students with disabilities—including temporary or permanent challenges with mental health, chronic health, sensory ability, physical health/mobility, and learning ability.

At Worcester State, the accommodation process is student-initiated. Please use this form to initiate your request for academic, housing, and/or dietary accommodations.

If you are not yet ready to request accommodations or have questions about the process, please contact sas@worcester.edu for more information and/or to request an informational meeting with a SAS staff member.

This form is designed to be completed by enrolled Worcester State students. If you are a member of the general public requesting accommodations for a University-sponsored event or program, please contact accessibility@worcester.edu.

First Name

Preferred Name

Last Name

WSU Student ID

WSU Email

Please use your university issued email address

Cell Number

Pronouns

Select all that apply

Specific Accommodation Information

How did you learn about Student Accessibility Services?

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My diagnosed disability falls into the following category

Functional Limitations

Please select any of the major life activities that you feel are significantly impacted by your disability.

Do you have any other functional limitations?

Are you requesting accommodation for a short-term/temporary disability?

A short-term/temporary disability may include concussions, medically-necessary and unexpected surgeries, broken bones or any other medical condition that is not long-term (conditions lasting longer than 3 months are considered long-term).

Are you requesting academic accommodations?

Academic accommodations in higher education are based upon access and are determined on an individual basis. Examples of educational accommodations include, but are not limited to, extended time for quizzes, tests and exams; reduced distraction testing location; and, lecture capture or permission to record class lectures.

Are you requesting housing accommodations? (E.g., air conditioning, assistance animal)

This housing accommodation process is a collaborative effort between Residence Life and Housing, Student Accessibility Services, Counseling Services and Health Services. Examples of housing accommodations include, but are not limited to, access to an accessible building, a shared bathroom with fewer people, a visual doorbell / strobe alarm, air conditioning, and an assistance animal.

Are you requesting dietary accommodations?

Many dietary needs can be accommodated by Campus Dining. In rare cases where a student’s medically-necessary dietary needs cannot be accommodated by Campus Dining, SAS works with students to identify whether a meal plan modification (exemption or reduced meal plan) is reasonable.

Would you like to register as a student with a disability without requesting accommodations at this time?

Please only select this option if you have not selected ‘yes’ to any of the questions above. We recognize that access needs can change, and you may not be sure or ready to request accommodations at this time. Select ‘yes’ here if you would like to have disability information on-file with the office. Please be aware that accommodations, once requested, cannot be applied retroactively.

Documentation

Disability documentation should be written by a licensed healthcare professional who is qualified to confirm your diagnosis and describe the functional impacts of the condition. Documentation can include an IEP / 504 Plan if those records include a disability diagnosis and a detailed summary of the evaluation that supported the determination of accommodations.

Please upload all documentation here:

Confidentiality of Information and Permissions

I understand that, in order to receive accommodations, Student Accessibility Services needs to interact and discuss information relating to accommodations with appropriate Worcester State University faculty members, administrators, and staff. These are individuals who would be involved in the administration of accommodations, the determination of accommodations (e.g., the Housing Accommodations Committee), and/or who may need to assist with meeting student access needs in a university environment on a need to know basis.

I grant permission for SAS to contact my diagnosing physician or other licensed provider(s) for clarification of my condition and recommend accommodations.

I authorize SAS to discuss and share information related to my disability and needs, in addition to academic accommodations and support services that I receive from SAS, with my parent(s) or guardian(s) for the purpose of assisting me in achieving my academic goals.

I understand that any of the authorizations above may be withdrawn by me at any time by submitting a written, signed, and dated request to Student Accessibility Services.