Students with Disabilities Requesting Accommodations Application

1. Start Term *: Select One 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring 2050 - Summer
   Note: Select when you would like to start your services.
2. Primary School *: Select One Arts, Science & Engineering Eastman Institute for Oral Health Eastman School of Music School of Nursing Simon School of Business URMC Graduate School URMC Medical School Warner School of Education
   Note: Please select campus location where you will be enrolled.
3. Expected Graduation Term: Select One 2012 - Fall 2013 - Spring 2013 - Summer 2013 - Fall 2014 - Spring 2014 - Summer 2014 - Fall 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring 2050 - Summer
   Note: Select when you plan to graduate.
4. First Name *:
5. Last Name *:
6. Middle Name:
7. Optional: Preferred Name:
8. Student ID:
   Hint: Enter 8 numeric characters, not your net ID.
9. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === ADHD === ADHD/ADD === Autism Spectrum Disorder === Autism Spectrum Disorder === Basic Chronic Medical Condition === Arthritis Cardiovascular Disorder Chronic Migraine Crohn's Disease Diabetes Fibromyalgia Other Basic Chronic Medical Condition POTS Sleep Disorder Ulcerative Colitis === Communication/Speech === Communication/Speech Disorder === Complex Chronic Medical Condition === ALS Cerebral Palsy Chronic Fatigue Syndrome Cystic Fibrosis Epilepsy Guillain-Barre Lupus Lyme Disease Multiple Sclerosis Muscular Dystrophy Other Complex Chronic Medical Condition === General Category === Other === Hearing === Deaf Hard of Hearing Other Hearing Impairment === Learning Disability === Auditory Processing Disorder Cognitive Disorder NOS Dyscalculia/Math Disorder Dysgraphia/Writing Disorder Dyslexia/Reading Disorder Language Disorder Learning Disorder NOS Other Learning Disability Processing Disorder === Mental Health === Bipolar Disorder Depression Eating Disorder Generalized Anxiety Disorder Obsessive Compulsive Disorder Other Mental Health Post Traumatic Stress Disorder === Mobility === General Mobility === Motor === Developmental Coordination Disorder Other Motor Disorder Tic Disorders Tremor === Orthopedic === Other Orthopedic Condition Scoliosis Spina Bifida Spinal Cord Injury === Temporary === OEI Temporary Medical Condition === Traumatic Brain Injury === Traumatic Brain Injury (not temporary) === Vision === Legally Blind Low Vision Other Visual Impairment
2. Secondary Disability(ies)

   ADHD

   ADHD/ADD

   Autism Spectrum Disorder

   Autism Spectrum Disorder

   Basic Chronic Medical Condition

   Arthritis

   Cardiovascular Disorder

   Chronic Migraine

   Crohn's Disease

   Diabetes

   Fibromyalgia

   Other Basic Chronic Medical Condition

   POTS

   Sleep Disorder

   Ulcerative Colitis

   Communication/Speech

   Communication/Speech Disorder

   Complex Chronic Medical Condition

   ALS

   Cerebral Palsy

   Chronic Fatigue Syndrome

   Cystic Fibrosis

   Epilepsy

   Guillain-Barre

   Lupus

   Lyme Disease

   Multiple Sclerosis

   Muscular Dystrophy

   Other Complex Chronic Medical Condition

   General Category

   Other

   Hearing

   Deaf

   Hard of Hearing

   Other Hearing Impairment

   Learning Disability

   Auditory Processing Disorder

   Cognitive Disorder NOS

   Dyscalculia/Math Disorder

   Dysgraphia/Writing Disorder

   Dyslexia/Reading Disorder

   Language Disorder

   Learning Disorder NOS

   Other Learning Disability

   Processing Disorder

   Mental Health

   Bipolar Disorder

   Depression

   Eating Disorder

   Generalized Anxiety Disorder

   Obsessive Compulsive Disorder

   Other Mental Health

   Post Traumatic Stress Disorder

   Mobility

   General Mobility

   Motor

   Developmental Coordination Disorder

   Other Motor Disorder

   Tic Disorders

   Tremor

   Orthopedic

   Other Orthopedic Condition

   Scoliosis

   Spina Bifida

   Spinal Cord Injury

   Temporary

   OEI

   Temporary Medical Condition

   Traumatic Brain Injury

   Traumatic Brain Injury (not temporary)

   Vision

   Legally Blind

   Low Vision

   Other Visual Impairment
3. Other Disability or Description of Temporary Medical Condition:
4. Seeking Degree *: Select One Graduate Other Undergraduate

Affiliation(s)

5. Affiliation(s)

   Brady, Handler, OR KRFrench Scholar

   Early Connection Opportunity (ECO)

   First Generation Student

   HEOP

   International

   Kearns Center

   Pre-College Program

   Transfer Student

   UR Transition

   Veteran
6. Additional Note:

1. Please tell us more about what you are seeking. *

   I am requesting accommodations for a disability.

   I am requesting temporary support for a medical condition.

   I am not requesting accommodations at this time but would like to register as a student with a disability with the Office of Disability Resources.

   I am submitting this form to explore whether I qualify for disability services. (In the following questions, please respond with as much information as you can and use "Not Applicable" where appropriate.)

   Additional Note or Comment
2. Are there accommodations that you are requesting that are not found in the selections above? Please specify. *
3. In your own words, please describe your disability barriers. *

   Explain (Specify Below)

   Not Applicable

   Additional Note or Comment
4. Would your disability hinder you from evacuating a building in an emergency? *

   Yes

   No

   Not Applicable

   Additional Note or Comment
5. Does your condition affect your transportation needs? If so, please explain. *

   Yes (Specify Below)

   No

   Not Applicable

   Additional Note or Comment
6. Do you anticipate using auxiliary aids, assistive technology, and/or other services while attending the University of Rochester (e.g. software, service dog, wheelchair)? *

   Yes (Specify Below)

   No

   Not Applicable

   Additional Note or Comment
7. Please review our documentation guidelines and submit appropriate documentation for your disability barriers. Please indicate how we should expect to receive your documentation. *

   I am uploading my disability documentation at this time. (You will be prompted to do so after you submit this form.)

   I will fax, mail, or hand deliver my disability documentation to Disability Resources. (See confirmation email message for fax number and mailing address.)

   I am not requesting disability services or accommodations right now and understand that disability documentation is not required at this time.

   Additional Note or Comment
8. By submitting this form, I certify that the information provided on this form is accurate. I understand that to be eligible for access accommodations at the University of Rochester, I must 1) submit this completed form, 2) submit disability documentation that substantiates the requested accommodations, and 3) participate in an initial individual assessment with a disability services professional. *

   I have requested disability accommodations and understand that a disability services professional will review my request and follow up with me.

   I have not requested disability accommodations but understand that if they are needed in the future, I will contact a disability services professional to discuss next steps.

   Additional Note or Comment