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3200 Grand Avenue

Des Moines, Iowa 50312-4198

515.271.1400

Student Request for Accommodations Form


Name:

Date Received:

Welcome to CASE! All information you provide as part of your accommodations application is
held confidential on a need to know basis by individuals involved in making accommodations
decisions for you in compliance with FERPA.
PART 1
[To be filled in by student prior to intake]
Background Information:
Street Address:
City:
E-mail:
Phone:
Age:
Date of Birth:
Place of Birth:
Gender:
Male
Female
Prefer Not to Disclose
Ethnicity:
Hispanic or Latino
Not-Hispanic or Latino
Race (check all that apply):
American Indian or Alaska Native
Asian
Black or African American
White
Native Hawaiian or Other Pacific Islander
Other: ____________________
Primary Language:
Other Language(s):
Veteran Status
Yes
No
New Student
Current Student
Major (Program of Study):
Current Course Load (Credit Hours):
Current Academic Standing: Year 1
2
3
4
Other:________________
Decelerated Program
Yes
No
Academic Probation
Yes
No
Participation in activities on campus:
Yes
No
Financial aid:
Yes
No
List of person(s) to be contacted in case of emergency:
Name
Relationship
Phone
Name
Relationship
Phone
Note: Diagnosis of a disability is necessary but not sufficient for accommodations.
Accommodations are intended to reduce the impact of functional limitations for students
with disabilities; how a disability impacts a particular student can be unique to that
student. Therefore, evidence of a specific functional limitation(s) is necessary prior to
accommodations being granted on a case by case basis.

Center for Academic Success and Enrichment


B. Pinney - July 2014

PART II
[To be filled in by student prior to intake]
How did you find out about this office? If referred, please indicate who referred you.

What accommodation(s) are you requesting:

Nature of the Impairment: (Check all that apply)


Psychological
Medical/Physical
Impairment
Impairment

ADHD
Learning Disability
Other:________________________
Temporary:____________________

Explain the nature of the disability (hearing/learning/visual/physical/psychiatric/other):

Have you used accommodations before? If yes, please explain which accommodations you
have used and how it has helped you.

In which of the following academic areas have you experienced difficulty?


Reading
Following through with directions
Writing
Memorizing/remembering
Spelling
Completing assignments on time/time
management
Math/Science
Test-taking
Organizing your schedule
Study skills
Registering for classes
Class/oral presentations
Seeking academic advisement
Foreign language
Assignments
Attendance
Identifying a major
Other:

Write a few sentences describing your academic difficulties in your own words.

High school GPA:


Undergraduate GPA:
In which of the following social/vocational areas have you experienced difficulty?
Making friends on campus
Talking to faculty
Talking to peers in and out of class
Making independent decisions
Anxiety about different elements of
Perceptions of what others are thinking
college life
Other:

Center for Academic Success and Enrichment


B. Pinney - July 2014

Write a few sentences about your social/vocational difficulties:

Do you have disability documentation that you have submitted or are able to submit?
Yes

No

If No, please explain:

Diagnosis:

How long ago was your disability first professionally diagnosed?


Not Diagnosed
< 1 year
1-2 years
2-4 years
5 or more years
Note: Accommodations are given for functional limitations resulting from a disability;
therefore an ADAAA recognized disability diagnosis is required to receive
accommodations.

Have you received prior test accommodations? Contact information will be requested at a
later time.

Standardized Examinations (e.g. SAT, ACT, MCAT, GRE, etc.)


Examination:

Yes

No

Yes

No

Yes

No

Yes

No

Month/Year:

Accommodation received (if extra time, note amount given):

Have you received College accommodations?


If yes, accommodations received:
School Received from:

Have you received Secondary school accommodations?


If yes, accommodations received:
School Received from:

Have you received Elementary school accommodations?


If yes, accommodations received:
School Received from:

Center for Academic Success and Enrichment


B. Pinney - July 2014

PART III
[To be filled in by student prior to intake]

Please describe how your disability manifests itself. How does it impact your learning and
testing? Please be as specific as possible.

Please explain how the requested accommodations help compensate for the functional
limitations you experience as a result of your disability.

Have you ever received any special tutoring, services, or medication for your disability?
Please describe each of these.

What compensatory learning/study strategies do you use to assist you in ameliorating the
impact of your disability?

Center for Academic Success and Enrichment


B. Pinney - July 2014

Please provide a personal statement describing your disability and its impact on your daily
life and educational functioning. There is no page limit for your personal statement, if you
need extra space feel free to attach additional pages with your submission.

I understand the provided information will assist the Accommodations Specialist in determining
the most effective accommodations and/or compensatory strategies for my use. I authorize the
Accommodations Specialist(s) and CASE to contact the professional(s) who diagnosed the
disability and/or those entities that have provided me with test accommodations or
documentation for further information if necessary. I authorize such professional(s) and entities
to communicate with Des Moines University in this regard and to provide Des Moines
University with such clarification and/or additional information.
Signature:

Date:

Please return this form and supporting documentation to: Accommodations Specialist,
Center for Academic Success and Enrichment, Des Moines University, 3200 Grand Ave,
Des Moines, IA 50312

Center for Academic Success and Enrichment


B. Pinney - July 2014