University College
Virginia Union University (VUU) is committed to providing students with disabilities/impairments equal access to all educational programs and opportunities. VUU’s policy on disability and accessibility is implemented in accordance with the Americans with Disabilities Act (ADA) of 1990 as amended, and Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of disability. The term “disability” may include learning, physical, sensory, psychological, medical, and certain temporary disabilities. Through the Office of Inclusive Learning, the University reviews student requests on an individual basis and provides a letter to outline eligible reasonable accommodations. Students with disabilities/impairments may request academic and housing accommodations, as well as other considerations or services as informed by appropriate documentation. If you have a disability/impairment and wish to request an accommodation, please complete the information below and return to the Office of Inclusive Learning. When completing the registration form, you may use additional paper to complete your responses, if needed. All email communications from the Office of Inclusive Learning will be sent to your VUU email address once assigned by the University.Student InformationNameHome AddressVUU Address (If Applicable)Preferred Phone NumberVUU Student ID NumberE-mail (VUU)Degree Program (Ex. Social Work, MDiv, etc)Enrollment Semester/YearEnrollment Status (choose all that apply): Current undergraduate student Current graduate student Full-Time Part-Time Residential (On-campus) Commuter (Off-campus)Diagnosed Disability/ImpairmentPlease use the chart below to indicate any Diagnosed Disability/Impairment: Type of Disability/ImpairmentSpecify: Please explain the nature of your disability/impairment and the date of diagnosisADD/ADHDHearing Impairment/DeafLearning DisabilityChronic Medical ConditionPhysical/MobilityPsychological/PsychiatricNeurologicalVisual Impairment/BlindOtherTemporary Condition Impact of Diagnosed Disability/ImpairmentTreatments and InterventionsPlease list any medications that you currently take as treatment for your disability/impairment, and any side effects that you experience.Describe any special equipment, assistive technology, mobility and/or auxiliary aids that you currently use, or have used in the past.Please respond to the questions below to indicate the extent to which your disability/impairment results in a functional impact:Explain how your disability/impairment impacts your ability to complete coursework or other program requirements.Explain how your disability/impairment impacts your daily activities outside of the classroom.Accommodations RequestedPlease use the chart below to indicate the specific accommodations that are being requested and the rationale for your request (Additional paper can be used to complete the responses, if needed): Accommodations Requested (Academic, Housing, Other)Include a rationale for your requestTemporary Accommodation RequestsIf your accommodation requests are temporary, please complete the following: Date of onset of impairment (MM/DD/YY)Anticipated Duration of ServicesDate of next follow-up medical appointmentReferralsIf you were referred to the Office of Inclusive Learning by a VUU faculty or staff member, please provide their name, title, and Department: Previous Approved AccommodationsHigh School, College, University Accommodations Previously Approved (Specify Accommodations)Did you use the approved accommodations? (Write: Yes, No, or Partially)Indicate the Dates Received: Month/Year – Month YearCertification and PermissionUnder the Family Educational Rights and Privacy Act (FERPA), the Office of Inclusive Learning may share information with appropriate University personnel on a need-to-know basis in order to facilitate the process of determining accommodation eligibility and/or implementation. In addition, the Office of Inclusive Learning’s evaluation may include review of your documentation by an external consultant engaged by the University. In limited circumstances, the disclosure of specific information may be required in order to protect individuals in an emergency or to comply with the law and/or University policies and procedures. As such, by providing the information below, I voluntarily give permission to the Office of Inclusive Learning and/or other University personnel to speak with or request information from the treating professional who provided or will provide documentation to support my accommodation request(s) if needed to make an accommodation decision. If provided, this authorization will expire upon my official exit from the university (either through formal withdrawal, removal, and/or program/degree completion).Name of Authorized Professional and Contact Information:NameTelephone NumberE-mail7524756591300I certify that the information entered on this form is accurate. I understand that my accommodation request(s) will not be considered until all appropriate documentation is submitted. I understand that my request for accommodation(s) will be reviewed on an individual basis. By signing below, I understand that the Office of Inclusive Learning is not a confidential resource.00I certify that the information entered on this form is accurate. I understand that my accommodation request(s) will not be considered until all appropriate documentation is submitted. I understand that my request for accommodation(s) will be reviewed on an individual basis. By signing below, I understand that the Office of Inclusive Learning is not a confidential resource.Signature:Date:Documentation Attached? (Y/N)Documentation GuidelinesAll accommodation requests must be supported by appropriate documentation completed by a qualified professional. Accommodation requests will not be considered until appropriate documentation is received. Please adhere to the following guidelines, as insufficient information may delay the accommodations process:For medical and physical conditions, documentation must be from a specialist (i.e., physician licensed professional psychologist, social worker, neurologist, psychiatrist, behavioral therapist, speech/language pathologist).Practitioners must follow their profession’s Code of Ethics related to qualifications and conflicts of interest.Documentation must provide a specific diagnosis (e.g. “Alex has a disability in the area of visual processing”) and/or impairment description, functional limitations, as well as any associated symptoms.Results of evidenced-based tests/assessments/standardized instruments to include the percentile comparison, as well as grade/age equivalents (if applicable)Documentation must explain the link between the disability/impairment, functional limitations, and the requested accommodations. Documentation should distinguish between school-based accommodations and strategies students should utilize on their own. Documentation must be: typed; dated; signed by the evaluator; and submitted to the Office of Inclusive Learning on professional letterhead in English.Dates on all documentation must not exceed five (5) years from the time the Request for Accommodations form is submitted. Note: An Individualized Education Plan (IEP) or 504 Plan, while helpful, may not be sufficient on its own without accompanying medical documentation for Office of Inclusive Learning to determine whether a student does or does not qualify for accommodations. ................
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