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First-Time UW-Superior Disability Accommodation Request
Please complete this form to the best of your knowledge.
*
indicates a required field
Student Information
Please enter your information
First Name
Required
*
Middle Name
Last Name
Required
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Preferred Name
UWS Student ID
Required
*
Email
Required
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Please enter your UW-Superior email address
Local/Cell Phone Number
Required
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Status
Please check all that apply
Domestic Student
First Generation Student
International Student
Non-degree Seeking Student
Online Student
Transfer Student
Veteran
Your Disability Information
Please share as much information as possible with us so we can best support you!
My disability(ies) falls into the following category(ies)
Required
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You can select multiple categories, just click on as many as apply.
My secondary disability falls into the following category
Leave blank if you do not have a secondary disability
Beyond the category above, please share your specific diagnosis(es):
Required
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Please describe how your disability impacts your learning.
Required
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Please indicate the accommodations you have received in the past or would like to request at this time.
Required
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Ability to take frequent breaks
Able to record classroom lectures & activities
Alternative text format
Assistive listening device
Audio recordings for test taking (of music, etc)
Emotional support animal in residence hall
Extended test time
In-class physical access aide
Low distraction testing environment
Preferential seating in classroom
Scribe for test taking
Service dog or service dog-in-training
Single room in residence halls
Test reader
Video captioning service
Other
If you selected Other above, please explain more about the accommodations you have received in the past
What is the name of your medical or mental health provider?
Required
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What is your medical or mental health provider's phone number?
Required
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Upload disability-related documentation here.
Examples: IEP, 504 Plan, Medical Diagnostic Document, Psychoeducational Report, etc.
Document Information
Document Title
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*
File
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Maximum file size: 10240kb
Description