Office of Accommodations and Disability Services APPLICATION FOR ACCOMMODATIONS

Bring this application and supporting documentation to your appointment.Middletown 540-869-0758 Fauquier 540-351-1517

Name: _____________________________________ Student ID Number: _____________

Address: ___________________________________ Telephone: (Day) _______________

___________________________________________ Telephone: (Cell) _______________

City State Zip

LFCC E-mail Address_________________________ Date of Birth _________________

When will the accommodations need to start? Fall Spring Summer Year: 20____

How did you learn about our services?

Access Syllabus Statement Adult Rehabilitation Agency Another Student College Instructor College Staff High School Staff Parent Orientation Website Other _____________________________________________________________________________________

Disability: Please check all that apply

Acquired Brain Injury Psychological/ Mental Health/Emotional ADD/ADHD Deaf/Hard of Hearing Speech Impairment Learning Disability Blind/Visual Impairment Mobility/Orthopedic Impairment Health Impairment Development Disability Language Impairment Other _____________________________________________________________________________________

Is the above condition: Permanent/Chronic/Unknown Temporary Note: If your medical condition is not permanent in nature, the college is not required by law to provide any accommodation, but ODS may be able to assist you on a temporary basis.

Educational History As far as you can recall, if you’ve had past difficulties in school and/or work, please describe your academic concerns: ____________________________________________________________________________________________

____________________________________________________________________________________________

If you are registered with Virginia Rehabilitative services, please check all appropriate boxes and complete a consent form to allow exchange of information between Disability Services and Rehabilitative Services.

Registered with Department of Rehabilitative Services Registered with Department for the Deaf and Hard of Hearing Registered with Department for the Blind and Visually Impaired

Accommodations

Based on your condition or disability, check any specific accommodations below you would like to apply for. (Accommodation

approval is based on supporting documentation and conversation with a counselor.)

Absence

Accessible site

Adjustable table

Alternate format test

Audio record lectures

Calculator

Closed Captioning

Computer

Distraction reduced site

Extended time

Interpreter

Large print

No scantron

Note Taker

Preferential seating

Reader

Space for wheelchair

Special seat

Spelling accommodation

Textbooks in alternate format

Other: _______________________________________________________________________________

*LFCC will not provide personal assistants, devices, and/or equipment. Our office will assist in making arrangements for these

accommodations when needed and requested.

Documentation

In order to be eligible for accommodations, you must provide the Office of Accommodations and Disability Services

documentation of your disability or condition that requires accommodation.

Criteria for documentation

1. A diagnostic statement identifying the disability and date of the most current diagnostic evaluation. A description of

the diagnostic tests, methods, and/or criteria used, which should follow adult norms.

2. A description of the current functional impact of the disability. There should be a description of how the individual’s

identified impairment substantially limits a major life activity. The description should include the current functional

impact on physical (including mobility and dexterity), cognitive (including processing, attention, and

communication), and behavioral abilities and should be described through specific results from the diagnostic

procedures.

3. A statement indicating treatments, medications, and assistive devices / services in use including a history of previous

academic adjustments and auxiliary aids and services and their impact. Recommendations regarding

accommodations should be reasonable within the academic setting.

4. The credentials of the professional(s), if not clear from the letterhead or other forms. Diagnosing professionals shall

not be family members or others with a close personal relationship with the individual.

5. Documentation should be current, occurring within the last three (3) years.

6. IEPs may not be sufficient documentation to support the need for academic accommodations. Please review your

IEP with disability services personnel to identify if additional documentation is required.

Additional supporting documentation beyond what is described above may be helpful, for example, copies of IEPs, 504 plans,

previous accommodations at another college, university, or job site, etc.

The Office of Accommodations and Disability Services must receive this form and appropriate documentation prior to

consideration and provision or approval of accommodations. Once documentation is received, it is the student’s

responsibility to schedule an appointment with the counselor on their campus to discuss accommodations, procedures, and

policies. Information contained within the file will be kept confidential and will not be shared with anyone outside of LFCC

without your express authorization. The college requests appropriate documentation of disability be submitted 30 days prior

to receiving approved accommodations.

The Office of Accommodations and Disability Services will exchange information with other relevant authorities on campus to

evaluate and facility the provision of accommodations. By signing this form you acknowledge and agree with this process.

Student signature: _____________________________________ Date: _________________________