Student Disability Accommodation Request Form Please enable JavaScript in your browser to complete this form.Student Information This form is to be completed by any student who is new to the Student Services department and will be used to connect you the the appropriate services. Forms should be sent to ss@bealuniversity.ca. Name: *FirstLastLayoutPreferred Name:Student ID # *Pronouns (optional)She/HerHe/HimThey/ThemZe/HirPrefer not to answerThis information is collected so that we may address you in the most inclusive way. Layout (copy)Date of Birth: *Email *Government Student Loans Are you eligible for Government Student Loan *YesNoNot SureDo you have a confirmed “Permanent Disability” status with Government Student Loan *YesNoNot SureDegree Level *Degree Level UndergraduateDegree Level DiplomaDegree Level MastersLayoutCell Phone: *Alternative Phone:Academic Standing Student Status (required) Please choose one of the following statements Multiple Choice *Student Status – New StudentStudent Status – Continuing student but new to requesting accommodationsAcademic Deadline - Do you have a pressing academic concern that requires attention? *YesNoDisability Information We acknowledge that the term "disability" makes some people uncomfortable and that some people may not be comfortable disclosing their disability or may not identify as having a disability. We use the term specifically with regards to protecting your rights and connecting you with the appropriate resources. Please indicate the disability you experience that has the greatest impact on your learning (optional)Acquired Brain InjuryConcussionAttention Deficit /Hyperactivity DisorderHearingVisionSpeechMedical: Chronic or PermanentMedical: TemporaryMental Health: ChronicMental Health: Newly IdentifiedMobility/ Dexterity Specific Learning DisabilityOtherPrefer not to disclose at this timeDetails: OtherIf you have selected “other” above, please specify the nature of your disabilityAdditional DisabilitiesIf you experience additional disabilities, please indicate them hereCurrent Functioning Impact on Learning or Daily Living (Required) *Please give a brief description of your disability and how it impacts your learning at university. Current Academic Concerns (Required) *What are your current academic concerns, needs or questions related to your disability? Temporary SituationIf this is a temporary situation, what is the expected duration? Please identify your strengths.Have you used any strategies that have helped you manage any particular challenges in your learning environment?Yes (please specify below)NoUncertainParagraph TextResources Please describe the supports, services or accommodations that you feel would support you at the University, based on your above noted concerns. Accommodations Prior to Beal University Canada (Required) Did you receive accommodations in high school or at other educational institutions or workplace? *Yes (please specify below)NoUncertainParagraph TextHave you used any other services at Beal University Canada, in addition to accommodations, in relation to your disability? (Counselling, Career Services, etc.) *Yes (please specify below)NoUncertainParagraph TextHave you used assistive software and/or technology to offset the impact of the disability on your studies (e.g. Read & Write Gold, Kurzweil, Dragon Naturally Speaking, Zoom Text, etc.)? *Yes (please specify below)NoUncertainParagraph TextHave you used any assistive devices in the past (e.g. a back support, an ergonomic chair, etc.)? *Yes (please specify below)NoUncertainParagraph TextPlease provide any other information that you think we should know about you. Documentation To protect the integrity of a rigorous academic environment, we require documentation verifying the existence of a disability from a registed health professional who is authorized to make a relevant diagnosis. Documentation Available? (Required)YesNoPlease note that documentation related to your request may be needed. Any documentation of a personal or medical nature can be submitted to the Student Services department, who will not share this documentation with others without your consent. Only information related to any functional restrictions or circumstances that require accommodation may be shared to meet your accommodation needs and with your consent. The confidentiality of your personal and/or medical information will be safeguarded by the Student Services department in accordance with privacy regulations. Student Acknowledgement & Agreement regarding Confidentiality I understand that the personal information related to my academic accommodation request, including any supporting documentation, shall be treated as strictly confidential, and shall not be disclosed to other persons without my consent. Information collected will remain separate from my student file. I understand that, in order to implement any academic accommodations, basic information may need to be shared with my instructor or others involved in the accommodation only to the extent necessary and only with my consent. LayoutSignature: *Clear SignatureDate: *Submit
