This form is to be used as a planning tool for the student requesting accommodations to prepare for meeting with Services for Students With Disabilities staff to develop an accommodation plan. The information requested below, any documentation regarding disability and need for accommodation will be considered confidential and will not be shared with any outside source without your permission. Requests for accommodation MUST be supported by documentation. Students requesting accommodations must meet with a Services for Students With Disabilities staff member to develop an accommodation plan. Students will present copies of the plans to their professors. Recommendations for accommodations rest solely with SERVICES FOR STUDENTS WITH DISABILITIES.
Name _________________________________ Email ______________________
Street Address ______________________________________ Zip _______________
Disability _________________________ VR Counselor _________________________
Phone/TTY ________________________ SSN ________________________
Past educational accommodations that you have used successfully. (please specify)
_______________________________________________________________________________
What classroom accommodations are you requesting?_____________________
_______________________________________________________________________________
What testing accommodations are you requesting?________________________
________________________________________________________________________________
What other accommodations are you requesting?_________________________
________________________________________________________________________________
Comments/Other requests ________________________________________________
Signature: ____________________________ Date: __________________
Please return completed form to:
Services for Students With Disabilities
PSTCC
10915 Hardin Valley Rd., P.O. Box 22990
Knoxville, TN 37933-0990