Initial Accommodation Request Form

Student Information

Please enter your information

Notice

Please read before continuing!

If you have already completed this form, you will not be able to submit it again. If you need to verify that you have already completed this form, you can:

Log in to Accommodate, and check the Accommodation menu on the left-side navigation to see if anything is filled in on your Accessibility Request.
Check your email for the confirmation email you should have received with the subject "

First NameRequired *

Last NameRequired *

Middle Name

Preferred Name

Pronouns

She, Her, Hers He, Him, His They, Them, Theirs She Her Hers He Him His They Them Theirs She, Her, Hers, They, Them, Theirs He, Him, His, They, Them, Theirs

Student ID (P-Number)Required *

Your student ID is a value that begins with the letter P. If you are a prospective student, please input your last name and your birthday formatted as MMDDYY (ie: Smith123456)

EmailRequired *

Please use your university issued email address. If you are a prospective student, please use your preferred email address.

Alternate Email Address

Phone NumberRequired *

Status (check all that apply):Required *

Prospective Student (Not Yet Admitted) Incoming Freshman Transfer Nontraditional First Generation Veteran Graduate Student Early College Current Student None of the above

Have you been accepted into the CU Achieve Program?Required *

Have you been accepted into the CU Achieve Program? Yes Have you been accepted into the CU Achieve Program? No

Home CampusRequired *

Please select the campus where you are primarily enrolled.

Specific Accommodation Information

Have you received accommodations at Commonwealth University (Bloomsburg, Lock Haven, Mansfield) in the past?

Have you received accommodations at Commonwealth University (Bloomsburg, Lock Haven, Mansfield) in the past? Yes Have you received accommodations at Commonwealth University (Bloomsburg, Lock Haven, Mansfield) in the past? No

At which location did you previously receive accommodations?Required *

Year Accommodations were ReceivedRequired *

Ex: 1995, 2014-2015

My disabilities or diagnoses fall into the following categories:Required *

If other, please specify:

How does your disability or diagnosis affect you academically?Required *

Please include any functional limitations like concentration, comprehension, reading, hearing, etc:

How does your disability or diagnosis affect you socially/personally?Required *

Check the areas affected by your current disability or diagnosisRequired *

Attention Concentration Math Memory/Recall Mobility Organization Processing Reading Reasoning Social Time Management Writing Other

If you checked other please explain the area that is affected by your disability or diagnosis

Explain what academic accommodations you are looking for.Required *

If you selected "Other" above, please explain more about the academic accommodation(s) you are requesting now:

Are you requesting Housing Accommodations?Required *

Are you requesting Housing Accommodations? Yes Are you requesting Housing Accommodations? No

Is your special housing request due to your disability according to the American with Disabilities Act (ADA)?Required *

Is your special housing request due to your disability according to the American with Disabilities Act (ADA)? Yes Is your special housing request due to your disability according to the American with Disabilities Act (ADA)? No

Have you completed the Special Housing Request Form on the Residence Life website?Required *

Have you completed the Special Housing Request Form on the Residence Life website? Yes Have you completed the Special Housing Request Form on the Residence Life website? No

Please select the housing accommodations you are requesting:Required *

Housing accommodations, other:

Academic History

What type of High School did you attend?Required *

High School NameRequired *

Did you have an IEP, 504 Plan or some other school-based support?Required *

Did you have an IEP, 504 Plan or some other school-based support? Yes Did you have an IEP, 504 Plan or some other school-based support? No

DocumentationRequired *

Documentation I do not have documentation Documentation I'm in the process of getting documentation Documentation I need assistance from UDS on how to get documentation Documentation I will submit documentation below

Upload supporting document(s)

Please upload documentation of disability from an appropriate professional, or forward separately to UDS. This could include an IEP or 504, Disability Verification Form, a letter from your medical provider, a Psychological Evaluation, or other documentation. All documentation should be signed and dated, and include medical license numbers when appropriate. Please refer to https://www.commonwealthu.edu/offices-directory/disability-services for more information about documentation requirements.

Drop files here to upload