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Disabilities: Individual Plan 

You may print this form or request one from
the ADA/504 Coordinator. For assistance or an alternative format, please contact the ADA/504 Coordinator at iveyr@nacc.edu or phone
extension 2322. 

Students with Disabilities home

Impairment and Disability Assessment

Individual Postsecondary Plan

Release of Information

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:

 


I. GENERAL INFORMATION

1. Name:

 

Student number:

 

2. Address:

 
   

3. Telephone: (Home)

 

(Work):

 

4. Date of Birth:

 

5. Semester entered at NACC: ( )Fall   ( )Spring   ( )Summer   Year:

 

6. Major:

 

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

  ____ 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

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

Semesters notification is requested:

 
 
 
 

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:   _______________________________________________