The Patrick John Higgins Center
P.O. Box 5005
Ashland, Virginia 23005-5505
804-752-7200 Extension 5510
Fax 804-752-7231

Office for Disability Support Services

ACCOMMODATION REQUEST FORM

Name:     Date:
Phone:     Box:
       
Name of Class   Name of Professor
Accommodations you are requesting
1.    
___ Extra time on tests & quizzes
___ Tests in a separtate room
___ No spelling penalties on in-class work
___ Word processing of tests
___ Student may tape record the lectures
___ Other:
       
2.    
___ Extra time on tests & quizzes
___ Tests in a separtate room
___ No spelling penalties on in-class work
___ Word processing of tests
___ Student may tape record the lectures
___ Other:
       
3.    
___ Extra time on tests & quizzes
___ Tests in a separtate room
___ No spelling penalties on in-class work
___ Word processing of tests
___ Student may tape record the lectures
___ Other:
       
4.    
___ Extra time on tests & quizzes
___ Tests in a separtate room
___ No spelling penalties on in-class work
___ Word processing of tests
___ Student may tape record the lectures
___ Other: