Request for Accommodation - Clarke University

This survey will take approximately 8-10 minutes to complete.

It is the first step in requesting disability accommodations for at Clarke University. A disability can be any condition that has a major impact on living, learning, or working. It can include, for example, physical and mental heath conditions, ADD/ADHD, LDs, TBIs or concussions, and conditions that impact mobility, hearing, seeing. If it is not evident, you may also need to submit documentation of your disability. For further information, see https://www.clarke.edu/academics/support-services-2/the-marc/accommodation-services/.

The information is kept confidential and will help us serve you better. Contact information is mandatory, but you may leave blank any other question you are uncomfortable answering.

After we receive your responses , we will reach out to discuss your accommodations. Please note that staff are available from August 1-May 31. Information sent in June and July will be acknowledged via email as soon as possible, but fully addressed in early August.

First Name*

Last Name*

Email Address - Your Clarke email address is preferred, but you may also add another that you check frequently. (Note that e-mail is not considered a secure form of communication for health/disability related details.)*

Phone Number

Is this a home number or mobile number?

Home

Mobile

Birthdate

Date of Entry to Clarke*

Are you a transfer student?

Yes

No

Where did you transfer from?

Disability and Accommodation History

This section helps us better understand your situation and your past use of accommodations. Remember that just because you used something in the past doesn't mean it is necessary now. On the other hand, you may need an accommodation now that you never used in the past.

We will use the information from this form and a personal meeting in conjunction with the documentation you provide to determine what is most appropriate at Clarke. See documentation information at https://www.clarke.edu/academics/support-services-2/the-marc/accommodation-services/

You may email, fax, mail, or hand deliver your documentation to the disability services coordinator. Contact information can be found at the link above.

In order to serve you best, please provide documentation prepared by a qualified professional. What type of documentation can you provide?

Upload Documentation Here

Do you have more documents to upload?

Yes

No

Upload Documentation Here

Do you have more documents to upload?

Yes

No

Upload Documentation Here

Do you have more documents to upload?

Yes

No

Upload Documentation Here

Do you have more documents to upload?

Yes

No

Upload Documentation Here

What is the nature of your disability? (ADD/ADHD, Autism Spectrum, Hearing or Visual, Learning Disability, Physical or Mental Health, TBI, etc.)

When were you first diagnosed?

In your own words, describe how your disability impacts you.

What accommodations have you used in the past? (i.e. extended time for tests, a separate room for tests, audio text, etc.)

What accommodations (including in academics, housing, dining, etc.) do you think you will need at Clarke?
For each accommodation, please explain how it helps you.

If applicable, please list adaptive/computer technologies that you will be requesting or using.

What else would it be useful for us to know?

By clicking this box, I acknowledge that the information I provided is true and accurate.*

Yes, this information is true and accurate.