Skip to content
Skip to main menu
Skip to secondary menu
Visit Site
Initial Accommodation Request
*
indicates a required field
Student Information
Please enter your information
First Name
Required
*
Last Name
Required
*
Middle Name
Preferred Name
Pronouns
She, Her, Hers
He, Him, His
They, Them, Theirs
Student ID
Required
*
Email
Required
*
Please use your university issued email address
Phone Number
Required
*
Specific Accommodation Information
Have you received accommodations from Lock Haven University in the past?
Required
*
Have you received accommodations from Lock Haven University in the past?
Yes
Have you received accommodations from Lock Haven University in the past?
No
Year Accommodations were Received
Ex: 1995, 2014-2015
My diagnosed disabilities fall into the following categories
Required
*
How does your disability affect you academically?
Required
*
How does your disability affect you socially/personally?
Required
*
Check the areas affected by your current disability
Required
*
Attention
Concentration
Math
Memory/Recall
Mobility
Organization
Processing
Reading
Reasoning
Social
Time Management
Writing
Other
If you checked other please explain the area that is affected by your disability.
Please describe the accommodations you are requesting
Required
*
Academic History
What type of High School did you attend?
Required
*
Public High School
Private High School
GED Program
Other
High School Name
Required
*
Did you have an IEP, 504 Plan or some other school-based support?
Required
*
Did you have an IEP, 504 Plan or some other school-based support?
Yes
Did you have an IEP, 504 Plan or some other school-based support?
No
Upload supporting document(s)
Please upload documentation of disability from an appropriate professional, or forward separately to ODSS. This could include a Psychological Evaluation, Psycho-educational Evaluation, Re-Evaluation Report, or other documentation. Please refer to ODSS Handbook at http://www.lockhaven.edu/adac/disabilityservices/ for more information about documentation requirements.
Campus Attending:
Required
*
Please prove you are not a robot
Document Information
Document Title
Required
*
File
Required
*
Maximum file size: 10240kb
Description