Accommodation Request

Student Information

While you may have concerns about returning to campus due to the global health pandemic know that the University is working diligently to plan and have broad scale measures in place, including but not limited to testing, symptom checking, contact tracing (when necessary) physical distancing, face covering guidelines and enhanced cleaning /disinfecting procedures. If you have specific concerns because of your own circumstances, please let us know by completing the form below.

Please complete any information relevant to your request.

Campus(Required) *

First Name(Required) *

Last Name(Required) *

Middle Name

Email(Required) *

Please use your university issued email address

Phone Number(Required) *

Radford Student ID(Required) *

Are you requesting alternate learning arrangements unrelated to a disability?(Required) *

Are you requesting alternate learning arrangements unrelated to a disability? Yes Are you requesting alternate learning arrangements unrelated to a disability? no

In the Event of an On Campus Emergency:(Required) *

In the Event of an On Campus Emergency: I do not live in university-owned housing.
In the Event of an On Campus Emergency: I live in university-owned housing and I have a concern that would require an emergency responder (i.e. mobility, visual, DHOH, etc.).
In the Event of an On Campus Emergency: I live in university-owned housing and I do not need assistance from an emergency responder.

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

Calculating No Impact
Calculating Moderate Impact
Calculating Substantial Impact
Calculating Don't Know

Concentrating

Concentrating No Impact
Concentrating Moderate Impact
Concentrating Substantial Impact
Concentrating Don't Know

Learning

Learning No Impact
Learning Moderate Impact
Learning Substantial Impact
Learning Don't Know

Time Management

Time Management No Impact
Time Management Moderate Impact
Time Management Substantial Impact
Time Management Don't Know

Reading

Reading No Impact
Reading Moderate Impact
Reading Substantial Impact
Reading Don't Know

Stress Management

Stress Management No Impact
Stress Management Moderate Impact
Stress Management Substantial Impact
Stress Management Don't Know

Taking Tests and Quizzes

Taking Tests and Quizzes No Impact
Taking Tests and Quizzes Moderate Impact
Taking Tests and Quizzes Substantial Impact
Taking Tests and Quizzes Don't Know

Writing

Writing No Impact
Writing Moderate Impact
Writing Substantial Impact
Writing Don't Know

Other Academic Limitations

Functional Limitations - Physical

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

Attending Class

Attending Class No Impact
Attending Class Moderate Impact
Attending Class Substantial Impact
Attending Class Don't Know

Breathing

Breathing No Impact
Breathing Moderate Impact
Breathing Substantial Impact
Breathing Don't Know

Caring for Oneself

Caring for Oneself No Impact
Caring for Oneself Moderate Impact
Caring for Oneself Substantial Impact
Caring for Oneself Don't Know

Hearing

Hearing No Impact
Hearing Moderate Impact
Hearing Substantial Impact
Hearing Don't Know

Seeing

Seeing No Impact
Seeing Moderate Impact
Seeing Substantial Impact
Seeing Don't Know

Physical Tasks

Physical Tasks No Impact
Physical Tasks Moderate Impact
Physical Tasks Substantial Impact
Physical Tasks Don't Know

Other Physical Limitations

Documentation and Submission

Acknowledgement(Required) *

I understand I may be asked to provide supporting information from a current treating professional (if applicable) and I may be asked to participate in an interview with a Center for Accessibility Services (CAS) coordinator.

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)?

How did you hear about the Center for Accessibility Services (CAS)? Admissions/High School Guidance
How did you hear about the Center for Accessibility Services (CAS)? Faculty
How did you hear about the Center for Accessibility Services (CAS)? Student
How did you hear about the Center for Accessibility Services (CAS)? Radford website
How did you hear about the Center for Accessibility Services (CAS)? Radford department

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