Confidential Student Accommodation Form

This form certifies that the following student has presented the necessary documentation to authenticate their disability.

The information contained in this document is CONFIDENTIAL and should not be disclosed to a third party without the express permission of the student
(see A.D.A. Title 1 at 42 USC ss12112(d)(3)&(4);29 cfr ss 1630.14-1630.16).
Any questions should be referred to the Office of Disability Service.

STUDENT NAME : Pat Brown

SS# : 123-45-6789

To equalize this student's chances for academic success, the following accommodations are necessary

Use of class note-taker

Use of tape recorder in classroom

Extended testing time for essay exams

Extended testing time for objective exams

Extended testing time for math exams

Testing in a distraction-reduced environment

STUDENT SIGNATURE : ________________________________ DATE ________

ODS STAFF SIGNATURE : ________________________________ DATE ________