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Print, fill out, and bring
or mail to the ADA/504 Coordinator.
STUDENT WITH A DISABILITY: INDIVIDUAL POSTSECONDARY PLAN
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Date: |
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Semester you plan to enroll: |
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I. GENERAL INFORMATION
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3. Telephone: (Home) |
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(Work): |
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5. Semester
entered at NACC: ( )Fall ( )Spring (
)Summer Year: |
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II. DISABILITY INFORMATION
7.
Disability type(s):
____ Blind
____ Chemical Dependency
____ Chronic Health Problems
____ Closed Head Injury
____ Deaf
____ Hearing Impairment |
____ Learning Disability
____ Motor/Orthopaedic Impairment
____ Psychological Disorder
____ Seizure Disorder
____ Speech Impairment
____ Visual Impairment |
8.
Clarifying information on disability, including medications:
9. What
problems or inconveniences, if any, does the disabling condition
cause in class?
10. What equipment, if any, is used in everyday living?
11. Is supporting documentation available? ( )Yes ( )No
Where filed or plans to obtain (if needed)?
12. Is handicapped parking required? ( )Yes ( )No
13. Can student climb stairs? ( )Yes ( )No
III. RELATED SERVICES RECEIVED
14. Were accommodations provided at previous college or in high
school? ( )Yes ( )No
Name of College/High School:
___________________________________________
Contact Person:
_____________________________________________________
Telephone # (if available):
_____________________________________________
15. If yes,
explain: ____________________________________________________
________________________________________________________________
16. Has
individual applied to the Division of Rehabilitation Services? (
)Yes ( )No
If yes, name of counselor:
_____________________________________________
VRS Office location:
___________________________________________________
Telephone:
__________________________________________________________
17. Is
individual registered with Recordings for the Blind? ( )Yes (
)No
18. Has the
individual applied for financial aid? ( )Yes ( )No
19. Is the
individual eligible for VA benefits? ( )Yes ( )No
20. Tuition
or other assistance is being received from the following:
_____VRS _____VA _____Financial Aid _____Employer
_____Other:
_____________________________________________________
IV.
ACCOMMODATIONS REQUESTED
21. Are
reasonable accommodations requested? ( )Yes ( )No
( )Interpreter ( )Notetaker ( )Test Reader
( )Test Scribe ( )Braille
( )Extended time on tests ( )Enlarged printed material
( )Taped testing
( )Alternate site w/proctor ( )Oral testing (
)Alternate test format
( )Preferential Seating ( )Temporary special parking permit
( )Lap board
( )Taped textbooks ( )Tape recorder in class (
)Electronic speller
( )Dictionary in class ( )Computer adaptations (
)Cue cards of formulas
( )Four-function calculator ( )Table in classroom
( )Other (explain):
22. With permission from the student (on a semester-by-semester
basis) this office will
notify faculty when a student with a disability who desires
reasonable accommodations
is enrolled in a class. Does student wish to have this service?
( )Yes ( )No
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Semesters notification is
requested: |
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IMPORTANT: Student must provide a schedule
of his/her classes to the Disability Services Office after
registration for each
semester he/she wants accommodations.
V. REFERRAL SERVICES INFORMATION PROVIDED
23. With permission, student referred to:
_____Student Affairs Office
_____ Dean of Instructions Office
_____Admissions Office
_____Financial Aid Office
_____Other NACC services: __________________________________________
24. Information was provided to the student (if not a client) on
the Division of
Rehabilitation Services. ( )Yes ( )No
Student Signature:
_______________________________________________
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