Request for Access/Accommodations

Request for Access/Accommodations

Individuals with disabilities are guaranteed certain protections and the right to reasonable accommodation when required for access. West Virginia State University (WVSU) is obligated to consider what reasonable accommodations will be provided when an individual follows the institutional process to properly identify to the university as a person with a disability and supplies the necessary documentation.
Name*

First NameLast Name
ID/A#
Email*
example@example.com
What is your relationship to the University?*

StudentCampus Visitor/Event ParticipantEmployee

Employee Request for Access/Accommodations
Employees who have conditions that preclude them from completing this form may request assistance through the Workplace Accessibility Program through the following contact methods -
- email - ada@wvstateu.edu
- phone or text - 681-533-0850
- office - 117 Sullivan Hall East, M-F, 8:30a-5:00p
This form is available in a print version by request.

This form is resumable, you can complete it in sections, save and complete it at a later date. Make sure to select the Save button at the bottom of the page.
Employee Name*

First NameLast Name
Employee ID #*
Employee Email*
example@example.com
Job Title*
Department*
As an employee of the institution, I am requesting -*

new or additional accommodationsthe same, previously approved accommodations

Condition and Limitations
Please describe how your disability impacts you by describing the limitation which is interfering with your ability to perform your job functions or access an employment benefit.
Documentation from an appropriate professional is part of the access consultation and reasonable accommodation determination process.

For job accommodation requests, you will need to have your medical provider fill out the Accommodation Request Medical Certification form.

For accommodations related to animals on university property, you will need to have a mental health provider fill out the Disability Verification Form.

If you do not have access to documentation of your diagnosis and how it impacts you, ask for a list of referral sources you can utilize.
Documentation Submission

Browse Files
If your provider has already completed the Medical Certification/Disability Verification or if you have additional documentation you wish to submit you can do so here Cancelof
Type of request - Employee

Accommodation for job dutiesAccommodation for animal in university propertyOther

Employee Request for Access/Accommodations
NOTE: This form must be completed by the employee requesting access/accommodations.

Individuals who have conditions that preclude them from completing this form may request assistance through Disability and Accessibility Resources by contacting the unit administrator, Michael Casey, via -

email - ada@wvstateu.edu
phone or text - 681-533-0850
office - 117 Sullivan Hall East

This form is available in a print version by request.

This form is resumable, you can complete it in sections, save and complete it at a later date. Make sure to select the Save button at the bottom of the page.
Job Duties
What, if any, job functions are you have difficulty performing due to your medical/psychological condition or disability?
What, if any, employment benefit are you having difficulty accessing?

Access/Accommodations
Have you had any accommodations in the past for the same limitation indicated on the previous page?*

YesNo
What were they and how effective were they?*
What specific accommodation(s) are you requesting now and how will it assist you?*
A workplace accommodation is a modification to policy or practice, the provision of tools and software, or a modification to the environment that lessens the impact of a disability to allow an employee to perform the essential functions of the job.
Provide any additional information that might be useful in processing your accommodation.*
Are you requesting to have an animal on university property as an accommodation?

YesNo

Accommodation Request for Animal in University Property
The approval of a particular animal requested by a resident of university housing as an emotional support animal is determined on a case-by-case basis through an interactive process involving the individual requesting the accommodation and relevant campus personnel to ensure the ESA -
1. is necessary to provide an individual with a disability an equal opportunity to use and enjoy University Housing; and
2. the animal will not fundamentally alter a University program, service or activity, pose an undue financial and/or administrative hardship, or pose a direct threat to the health or safety of other individuals, or cause substantial damage to the property of other individuals or the University.
This may require the University to assess the impact of an ESA on other campus residents, patrons, or programs.

The University will accept and consider a request for an ESA at any time. The individual making the request for an ESA should complete the accommodation request process with the Disability and Accessibility Resources unit as soon as possible prior to moving into University Housing. The process includes completion of the Request for Accommodations form and submission of the Disability Verification Form and documentation verifying the need for an ESA.

If the request for an ESA is made fewer than 60 days before the individual intends to move into University Housing, the University cannot guarantee that it will be able to meet the ESA request during the initial term of occupancy. If the need for an ESA arises when the individual already resides in University Housing, the University will work with the individual but cannot guarantee that the ESA request can be met in a timely manner.

An animal may not be brought into University Housing without expressed approval from a designee of the Division of Business and Finance.

As part of the ESA approval process, a Housing representative will liaise with the Disability and Accessibility Resources unit. The disability unit staff will provide the Housing representative with the following information:
- Whether the ESA accommodation is approved.
- ESA species and all other relevant information (e.g., age, weight, height, housebroken status, etc.)
All requests for an ESA in University Housing are subject to an annual review.
By signing here, I am indicating that I have read and understand the information above regarding the ESA process.

Clear
Explain how the requested accommodation of an animal in university housing is based on the impacts and limitations associated with your condition and why it is necessary to create access for you? (refer to instructions below)
Provide a brief description indicating how the requested accommodations are associated with your disability related needs. In other words, based on the impacts of the condition - how will the requested accommodations assist you in overcoming the barriers you experience in the housing setting. This is not the diagnosis itself or because it was recommended by a medical provider.

SUBMISSION PAGE
This form initiates a request for a workplace accommodation due to your own medical condition. This will begin communications to evaluate your requested accommodation(s) and discuss the best way to meet the needs of both you and the Institution. Please note that you may be required to submit a timely, complete, and sufficient certification from an appropriate health care provider to support your request for accommodation, and the failure to timely and fully comply with such documentation requirements, or to cooperate in this process, may result in delay or denial of your request.

By submitting this form, typing my name and signing below, I affirm that I -
- am an employee at WVSU
- have provided accurate and complete information regarding myself
Name

First NameLast Name
Signature

Clear
Access Consultation

All new accommodation requests require an access consultation with the Director of DAR.

Those with previously approved accommodations may also request a consultation to discuss the effectiveness of the accommodations.
Is this a new accommodation request or do you want an access consultation for previously approved accommodations?

YesNo
Appointment Scheduling*
Enter the confirmed appointment date (use link above to confirm an appointment.*

MonthDayYear
Enter the confirmed time for the appointment.*

:HourMinutesAM/PM Option

Review of Previously Approved Accommodations
What are the specific accommodations you wish to continue utilizing for the coming year?
Have there been any significant changes in your condition or functional limitations in the past year?

YesNo
Please explain what has changed in your condition or functional limitations.
Have the accommodations you outlined above been effective in allowing you to overcome the barriers you experience in the workplace?

YesNo
Please explain why they have not been effective.
Are there any of the essential duties of your job you have been unable to do because of your condition and functional limitations?

YesNo
Please explain which essential duties you have not been able to do.
Are there any employment benefits of your job you have been unable to access because of your condition and functional limitations?

YesNo
Please explain which employment benefits you have not been able to access.

Enter the confirmed appointment date and time (use link above to confirm)*
SUBMISSION PAGE
This form continues a request for a workplace accommodation due to your own medical condition.

By submitting this form, typing my name and signing below, I affirm that I -
- am an employee at WVSU
- have provided accurate and complete information regarding myself
Name

First NameLast Name
Signature

Clear
Access Consultation

Those with previously approved accommodations with no significant changes to their condition may request a consultation to discuss the effectiveness of the accommodations but it is not required.
Do you want an access consultation for your previously approved accommodations?

YesNo
Enter the confirmed appointment date (use link above to confirm an appointment.

MonthDayYear
Date
Enter the confirmed time for the appointment.*

:HourMinutesAM/PM Option
Enter the confirmed appointment date and time (use link above to confirm)*

Student Request for Access/Accommodation
Enrollment/Registration Status

Not yet admittedAdmitted but not registered for coursesAdmitted and registered for coursesContinuing studentEarly Enrollment/Dual Enrollment

NOTE:

FOR STUDENTS NOT REGISTERED FOR COURSES

Final approval of academic accommodation options are dependent on your schedule of courses for which you are registered. The access consultation should be scheduled for a time after you will register or have registered for classes.

For incoming freshmen or transfer students - You are encouraged to register for the earliest possible New Student Orientation date, for fall admission it is typically in May. This will allow sufficient time for you to register for classes and scheduling your access consultation prior to the start of the semester.
By typing my initials below and proceeding with my request, I understand the final decision regarding approval of any academic accommodations will be pending until such time as I am registered for courses for the given semester in which I intend to utilize the accommodations.

Treatment (Temporary Conditions)
Are you currently under the care of a professional/specialist (ie, physician, athletic trainer, counselor, psychologist, etc.)?*

YesNo
Please specify name(s) and speciality(ies)
When are your next scheduled appointments?
What modifications to your daily routine have been recommended by the specialist(s)?
Describe the types of treatment you are/will be receiving.
Are you currently taking medications relevant to your condition?

YesNo
List the medications.

SUBMISSION PAGE
ACCESS CONSULTATION APPOINTMENT

All requests for new accommodations must include an access consultation with the Director.
Access Consultation Scheduling*
Enter the date of the confirmed appointment (use link above to confirm)*

MonthDayYear
Enter the time of the confirmed appointment*

:HourMinutesAM/PM Option
Enter the confirmed appointment date and time (use link above to confirm)*
By submitting this form and typing my name below, I affirm that I -
- am a student at West Virginia State University
- have personally completed this form in it's entirety
- have provided accurate and complete information regarding myself
Name

First NameLast Name
Signature

Clear

SUBMISSION PAGE

By typing my name below and submitting this form, I affirm that I -
- am a currently enrolled student at West Virginia State University
- am registered for the courses I will take for the semester
- have personally completed this form in it's entirety
- have provided accurate and complete information regarding myself
Name

First NameLast Name
Signature

Clear
ACCESS CONSULTATION APPOINTMENT

All requests for new accommodations must include an access consultation with the Director.
Select a day and time for your access consultation.*
Enter the date of the confirmed appointment (use the link above to confirm appointment)*

MonthDayYear
Date
Enter the time of the confirmed appointment*

:HourMinutesAM/PM Option
Enter the confirmed appointment date and time (use link above to confirm)*

Approved Accommodation Requests

If you have previously been approved for any of these accommodations at WVSU, you may make the request to utilize these accommodations for the upcoming/current semester here.
Type of Accommodation Request

Digital TextbooksDigital Note Taking Services or Peer Note Taker

	CRN
Course 1
Course 2
Course 3
Course 4
Course 5
Course 6
Course 7
Course 8

Submission Page
By submitting this form and typing my name below, I affirm that I -
- am a student at West Virginia State University
- have personally completed this form in it's entirety
- have provided accurate and complete information regarding myself
Name

First NameLast Name
Signature

Clear
Would you like to have an access consultation to discuss any changes in your condition, discuss any concerns or review the effectiveness of your previously approved accommodations?*

YesNo
ACCESS CONSULTATION APPOINTMENT
Appointment Request
Enter the confirmed appointment date and time (use link above to confirm)*

Unfortunately, this is not the correct form to utilize for your situation.

If you are interested in dicussing your circumstances with the Director of Disability and Accessibility Resources and exploring the options and resources which might be available to you once you are admitted and registered for courses -

click here to submit an interest/inquiry form.

Campus Visitor Request for Access/Accommodation
Individuals who have conditions that preclude them from completing this form may request assistance through Disability and Accessibility Resources by contacting Michael Casey, ADA Coordinator/504 Compliance Officer at -

email - ada@wvstateu.edu
phone or text - 304-552-5868
office - 117 Sullivan Hall East

This form is available in a print version by request.

This form is resumable, you can complete it in sections, save and complete it at a later date. Make sure to select the Save button at the bottom of the page.
Name of Person Requesting Accommodation*

First NameLast Name
Phone Number

Area CodePhone Number
Email*
example@example.com
My diagnosed disability falls into one or more of the following categories:*

Cognitive Impairments (Learning Disability, Traumatic Brain Injury, etc)Mental/Emotional DisordersSensory Impairments (Blind/low vision, deaf/hard of hearing)Orthopedic/Mobility/Dexterity Impairments (difficulty walking, standing, sitting, manipulating objects)Health Impairments/Allergies/Chronic or temporary medical conditionUnknown/UnsureOther
What specific accommodation(s) are you requesting now and how will it assist you with participating in the university program or event?*
Date accommodation(s) are needed*

MonthDayYear
Date
If you are participating in a WVSU program, list the program, locations and duration of the program.
If you are attending a WVSU event, list the location(s), date(s), and time(s) of the event(s)*
If not applicable, put in
Signature

Clear
Should be Empty:

	YES	NO
Did you have an IEP or 504 plan in middle or high school?
Have you seen a diagnosing or treatment professional in the last five years?
Have you had an assessment/evaluation of your impairment within the last five years?
Are you currently a client of the WV Division of Rehabilitation Services (or comparable agency in your home state)?
Do you have current records of your diagnosis and how it impacts you?

	YES	NO
I understand I must allow 2 weeks to obtain digital textbooks because they are dependent on publisher's approval and availability.
I understand although I may prefer one format over another, SAR does not have control as to which format will be available from the publisher.
I understand there may be times when some text will not be available in an electronic/alternative format and that I must allow a reasonable time frame in order for SAR to request permission from the publisher and produce an alternative textbook version.
I understand all digital/alternative textbooks must be returned to SAR, or deleted from my computer, by the last day of the semester.

	Course CRN	Textbook ISBN	Textbook Year
Textbook 1
Textbook 2
Textbook 3
Textbook 4
Textbook 5
Textbook 6
Textbook 7

	YES	NO
I understand it is my responsibility to contact each faculty member before using a recording device to inform him/her that a device will be used in class.
I understand that information contained in the recorded lecture is protected under federal copyright laws and may not be published without the consent of the lecturer.
I agree that I will not share, send, post publish, make public, or duplicate any recordings without the written authorization of the recorded person(s).
I understand that failure to abide by these rules may render me liable to the faculty member and members of the class for breach of privacy and violation of copyright laws.
If using a recording device for note-taking, I agree that recording classes is permissible solely to facilitate my note-taking accommodation and for no other purpose.
I agree to destroy my recording of any classes at the end of the semester. If my recording is for a class that I need to refer to in the future, I agree to destroy my recording at the completion of any courses that are dependent on this course.
I understand that failure to abide by these rules is considered a serious violation of West Virginia State University standards and subject to disciplinary action.

	YES	NO
Do you want your identity to remain anonymous/confidential from the peer note taker?
I understand that if I am requesting that my identity remain anonymous/confidential, it may take longer to identify and obtain a note taker.

Request for Access/Accommodations

Employee Request for Access/Accommodations

Condition and Limitations

Employee Request for Access/Accommodations

Access/Accommodations

Accommodation Request for Animal in University Property

SUBMISSION PAGE

Access Consultation

Review of Previously Approved Accommodations

SUBMISSION PAGE

Access Consultation

Student Request for Access/Accommodation

NOTE:

FOR STUDENTS NOT REGISTERED FOR COURSES

Condition and Issues (Temporary Conditions)

Treatment (Temporary Conditions)

Accommodations (Temporary Conditions)

SUBMISSION PAGE

ACCESS CONSULTATION APPOINTMENT

COVID Related Modifications

SUBMISSION

Condition and Issues (Permanent/Disability)

Current Issues

Accommodations (Permanent/Disability)

Academic Accommodations

Testing Accommodations

Alternative Text

Alternative Format Textbooks or Course Materials

Classroom Accommodations

Accessible Media

Computer Accessibility

Attendance/Class Participation, Test Dates or Deadline Flexibility

SUBMISSION PAGE

ACCESS CONSULTATION APPOINTMENT

Current Issues - Indicate if any of the below are current issues for you

Approved Accommodation Requests

Digital/Electronic/Alternative Textbook Request

Note Taking Accommodations

Submission Page

ACCESS CONSULTATION APPOINTMENT

Campus Visitor Request for Access/Accommodation