I understand that I must submit evidence of my disability from a qualified professional. Further, I understand ... Fax:
Point Park University Disability Services Program for Academic Success IDENTIFICATION & NEEDS ASSESSMENT (Please print or type information)
I. STUDENT DATA
Date ________________
ID # _____________________ Name________________________________________________________________ Permanent Address_____________________________________________________ Local Address/Campus Box_______________________________________________ Home Number____________________________ Cell Number _____________________________ E-mail___________________________________ University Entry Date________________
Transfer: Yes_____ No_____
Class Standing: ___Freshman ___Sophomore ___Junior ___Senior ____PB/Graduate
II. DISABILITY INFORMATION Please indicate your disability and the resulting functional limitations. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please list your requested accommodations. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Identification & Needs Assessment – Page 2
III. RESPONSIBILITIES AND PERMISSION I understand that I must submit evidence of my disability from a qualified professional. Further, I understand that my documentation should meet the guidelines established by Point Park University and that it will be used in determining reasonable accommodations. I understand that I must participate in an interview with the coordinator of disability services to discuss requested accommodations. Furthermore, I understand that reasonable accommodations are determined by the coordinator of disability services. Each semester that I want accommodations, I will contact the coordinator of disability services to request on-going accommodations or to discuss adjustments to accommodations. Further, if applicable, I will request an information memo for my instructors and speak to my instructors about the accommodations determined by the coordinator of disability services. I should discuss any concerns or problems related to the provision of reasonable accommodations with the coordinator of disability services. I AUTHORIZE THE PAS OFFICE TO CONTACT POINT PARK UNIVERSITY FACULTY AND STAFF, ON A NEED-TO-KNOW BASIS, REGARDING THE INFORMATION I HAVE PROVIDED. _____________________________________ Student’s Signature
Submit this completed form and the supporting documentation to: Patricia Boykin Director & Coordinator of Disability Services Program for Academic Success Point Park University 201 Wood Street Pittsburgh, PA 15222 Telephone: 412-392-4738 Fax: 412-392-3884 Email:
[email protected]
January 2011
_________________ Date
