Access and Disability Services

Service Request

STUDENT INFORMATION

Name: ____ Date:______

Email: Home Phone: Cell Phone: ______

PLEASE ANSWER THE QUESTIONS BELOW:

Degree: (circle) Ed.M / CAS / Ed.D / Ph.D Program: __Expected Graduation Year:__

Academic Advisor: Date(s) Diagnosed:______

Please describe (1) your disability and (2) its anticipated impact on your academic and student life:

______

Please describe previous accommodations, including academic, residential, medical, therapeutic, facilities access, technology, time adjustments, transportation, etc. :______

______

CLINICAL DOCUMENTATION:

Name of Clinician/Evaluator: ____ Phone/Fax/Email:______

Address:______

Name of Clinician/Evaluator: ____ Phone/Fax/Email:______

Address:______

I will send documentation separately (date): ______

I will need assistance in providing documentation: (circle) YES NO

I prefer to meet with the Access & Disability Services Administrator on (date): ______

ANTICIPATED NEEDS:

Please check anticipated needs based on your documentation:

Please note this list is not exhaustive.

Access Technology

Alternative format course materials (e-text, hard copy, captioning, video/image descriptions, etc.)

Braille/ Mobility orientation

Remote CART/ Sign Language Interpreter

Note Takers

Van Transportation

Housing Accommodations (for students with disabilities)

Time adjustments (assignments, degree program, etc.)

Referrals to University and outside resources

Other: ______

Mail this form and your clinical documentation to:

Eileen Connell Berger

Access and Disability Services Administrator

Assistant Director of OSA

Harvard Graduate School of Education

Gutman Library 124 A & B

6 Appian Way

Cambridge, MA 02138

Phone (617) 495-9608; Fax (617) 496-8024;

The information I have provided is accurate to the best of my knowledge. I authorize Eileen Berger, HGSE Access and Disability Services Administrator to consult, as needed, with clinicians to clarify documentation.

______

Student Signature

Request for disability accommodations is a four-step process:

· Disclosure of disability through Access and Disability Services Request Form and clinical documentation (Disclosure and requests are confidential)

· Initiation of request(s) for services via service request form, phone (617-495-9608), or email ()

· Evaluation of request(s) and clinical documentation by HGSE Access and Disability Services Administrator

· Individual meeting with HGSE Access and Disability Services Administrator in-person, via Skype (hgse.ads), phone (617-495-9608), or email ()

· If possible contact ADS before course registration—however, your request is welcome at any time