New Accommodation Request

Student Information

For Radford University or Radford University Carilion students with a disability who would like to request accommodations. Please complete any information related to your disability.

Campus

First Name

Middle Name

Last Name

Preferred Name

Pronouns

Radford Email

Please use your university issued email address

Phone Number

Radford Student ID

In the Event of an On Campus Emergency:

Specific Accommodation Information

State the disability (includes medical condition, chronic disease, recovery from addiction, temporary or permanent issues)

Describe how the issue impacts success on the college campus

Previously Received Accommodations

Please list accommodations you previously received related to this concern.

What accommodations are you requesting

Functional Limitations - Academic

Calculating

Concentrating

Learning

Time Management

Reading

Stress Management

Taking Tests and Quizzes

Writing

Other Academic Limitations

Functional Limitations - Physical

Please indicate the level of impact on applicable major life activities due to the diagnosis(es).

Attending Class

Breathing

Caring for Oneself

Hearing

Seeing

Physical Tasks

Other Physical Limitations

Documentation and Submission

Acknowledgement

If applicable, upload supporting document(s)

Documentation examples include IEP, 504, psychological testing, doctor's letter

Acceptable formats include: .docx, .pdf.

How did you hear about the Center for Accessibility Services (CAS)?