Prospective Student Accommodations Request Form

Services for Students with Disabilities Office

The Services for Students with Disabilities Office is here to assist you with any barriers you may encounter while you are at Winston-Salem State University student or employee. The Services for Students with Disabilities Office works to ensure all WSSU faculty, staff and enrolled students have an equal opportunity to participate in all aspects of collegiate life.

The singular most important issue is equal access. Please take the time to complete the accommodation request form. Once your documentation and request form are received, you will be contacted to make sure this office is clear about how we can be of assistance.

This form is to be completed by any prospective Winston-Salem State University student that may be seeking accommodations through the WSSU Services for Students with Disabilities Office.

If you are an enrolled student at WSSU, please log into Accommodate to submit your form. Please do not use this form if you are an enrolled WSSU student.

How to Get Started with Accommodations

Students who need accommodations should follow the process to get connected to Services for Students with Disabilities. Our documentation guidelines and detailed information on how to register for services can be found on our website. Students new to the Services for Students with Disabilities Office should submit their documentation through the secure SSD Student Portal.

Student Agreements

Place a check mark inside each check box to affirm the following.

Student Confirmation

Disability Eligibility Review

Documentation Requirements

Cost Responsibilities

Documentation Responsibilities

Prospective Student Information

First Name

Last Name

Email

Phone Number

Tentative WSSU Entering Year

Tentative WSSU Entering Term

Transfer Student

Specific Accommodation Information

My diagnosed disability falls into the following category

Specific Diagnosis

Please list your disability diagnosis below

Limited Major Life Activity

Desired Accommodations

How do you think accommodations will help?

Other Agencies/Supports

Prescribed Medication

Completed Form Review Period

Generally, students are notified within ten business days of submission, if you have not received communication from the Services for Students with Disabilities Office within this timeframe, please contact our office.

Documentation

Upload supporting document(s)

Institutional Procedures

A written narrative must be submitted on letterhead of the licensed professional supplying their professional opinion as it relates to their interactions and observations correlating to the specific diagnosis. This must adequately support each accommodation recommended and must include responses for 1-7:

1. Name of Impairment(s) and DSM-V or ICD code associated with each.

2. A full description of the current difficulties and functional limitations caused by each impairment.

What major life activities are affected?

3. When the impairment was first diagnosed/treated by your office and whether the disability is temporary (estimated duration), episodic (estimated length of episodes and frequency), or permanent;

4. Information about what medication is prescribed and how any prescribed medication and/or other corrective measures may improve the impairment. Please include whether or not accommodations will be needed when utilizing medication or other corrective measures;

5. Activities or situations that should be avoided or would present a current significant risk of serious injury or death for the requestor or others;

a With the restrictions listed, would you considered this person is essentially qualified to pursue their current role at this time?

b Are there any concerns for safety?

6. A clear and convincing rationale for each requested accommodation based on the degree of impact of the impairment and the resulting functional limitations.

How will these accommodations mitigate the affected major life activities?

7. Licensing credentials of person preparing the narrative.

OR

The latest psychological examination

The Services for Students with Disabilities Office will make the final determination about the adequacy of disability documentation. All documentation is confidential. Decisions are communicated to the requestor.

Some types of documentation are INSUFFICIENT:

• Documentation consisting only of a diagnosis, recommendation, case or chart notes and/or prescription notations is insufficient to qualify persons for services and accommodations.

In cases where the documentation is incomplete, individuals will be required to submit additional information. This will delay accommodation decisions.