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 NameRequired *

Middle Name

Last NameRequired *

Preferred Name

UWS Student IDRequired *

EmailRequired *

Please enter your UW-Superior email address

Local/Cell Phone NumberRequired *

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 *

Please select only ONE diagnosed disability. If you have multiple diagnosed disabilities, please enter those in the following question about secondary disabilities.

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 *

Please describe how your disability impacts your learning.Required *

Please indicate the accommodations you have received in the past or would like to request at this time.Required *

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 *

What is your medical or mental health provider's phone number?Required *

Upload disability-related documentation here.

Examples: IEP, 504 Plan, Medical Diagnostic Document, Psychoeducational Report, etc.

Document Information

Document Title

FileRequired *

Maximum file size: 10240kb

Description