Student Accommodation Intake Form

Student Information

Please enter your information

First Name

Last Name

SCSU Student ID

Email

Please use your university issued email address

Cell Phone Number

Date of birth

Specific Accommodation Information

Purpose for Accommodation Request

Other Reason for Request

Please include specific information related to your request for accommodations.

How does the condition/status above impact you at Southern?

Please describe any accommodations you have previously received.

Please describe any accommodations you believe you need currently.

Documentation requirements

Students who seek support services from Accessibility Services are required to submit current documentation to verify eligibility as defined under section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Protection under these civil rights statutes is based upon documentation of a disability that currently substantially limits at least one major life activity.

*Ask CASAS staff for a detailed copy of the documentation guidelines or download a copy at http://inside.southernct.edu/casas/accessibility-services

Upload supporting document(s)

Student Accommodation Intake Form

Student Information

Specific Accommodation Information

Documentation requirements

Document Information