MSU - Disability Services

Accommodation Request Summary

Student Name:

MSU ID #:

Campus: MSU DCB Other:

Semester: Fall Spring Summer

Courses needing accommodations:

Course 1 Course: (ex. Math 103)
Professor:
Accommodations(s) requested for this course:
Alternate format/E-text Request
Note Taker
Testing Accommodations
Other:

Course 2 Course: (ex. Math 103)
Professor:
Accommodations(s) requested for this course:
Alternate format/E-text Request
Note Taker
Testing Accommodations
Other:

Course 3 Course: (ex. Math 103)
Professor:
Accommodations(s) requested for this course:
Alternate format/E-text Request
Note Taker
Testing Accommodations
Other:

Course 4 Course: (ex. Math 103)
Professor:
Accommodations(s) requested for this course:
Alternate format/E-text Request
Note Taker
Testing Accommodations
Other:

Course 5 Course: (ex. Math 103)
Professor:
Accommodations(s) requested for this course:
Alternate format/E-text Request
Note Taker
Testing Accommodations
Other:

Please read each statement and check the box.

I request the above accommodations and agree to provide Disability Services (DS) with information on a timely basis so there is a reasonable time for accommodations to be arranged by DS (e.g., alternative format).

I also agree to immediately inform DS should my need for accommodations change.

I understand that this form must be completed EACH SEMESTER in order that my accommodations be approved and facilitated.