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Print, fill out, and bring
or mail to the ADA/504 Coordinator.
STUDENT WITH A DISABILITY: INDIVIDUAL POSTSECONDARY PLAN
Date: ___________________ Semester you plan to enroll:
____________________
GENERAL INFORMATION
1. Name:
____________________________________ SSN: ___________________
2. Address:
__________________________________________________________
_________________________________________________________________
3.
Telephone: (Home) _______________________ (Work)
_____________________
4. Date of
Birth: ___________________________________
5. Semester
entered at NACC: ( )Fall ( )Spring ( )Summer Year:
________________
6. Major:
_____________________________________________________________
DISABILITY INFORMATION
7.
Disability type(s):
____ Blind
____ Learning Disability
____ Chemical Dependency
____ Motor/Orthopaedic Impairment
____ Chronic Health Problems
____ Psychological Disorder
____ Closed Head Injury
____ Seizure Disorder
____ Deaf
____ Speech Impairment
____ Hearing Impairment
____ Visual Impairment
____ Other:
__________________________________________________________
____________________________________________________________
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
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:
______________________________________________________
III.
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 -emester
basis) this office will
notify faculty when a student with a disability who desires
reasonable accommodations
is enrolled in a course. Does student wish to have this service?
( )Yes ( )No
Semesters notification is requested:
______________________________________
___________________________________________________________________
___________________________________________________________________
*Student must provide a schedule to this office upon
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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