Missouri State

West Plains

Application/Request for Accommodations

Request Term

Personal Information First Name: * Last Name: * Bearpass #: Email Address: * Address: City: State: Zip: Home Phone: CellPhone: Major: Academic Status:

Type of Disability Blind/Low Vision
Health Related
Acquired Brain Injury
Learning Disability
Deaf/Hard of Hearing
Orthopedic
Chemical Dependence
Deaf/Blind
ADD/ADHD
Psychological
Autism
Enter disability not listed.

* Not provided by the University

Requested Accommodations for Learning Environment Priority Registration
Braille
Large Print
Alternative Textbooks
Disability Related Absence
Video Captioning/Transcription
Preferential Seating
Accessible Site
Adjustable Tables
Space For Wheelchair
Sign Language Interpreter
CART/Transcription
Note Taker
Lab Assistant
Service Animal *
Personal Care Attendant *

Requested Accommodations for Equipment Assistive Listening Device
Assistive Technology
Low Vision Aids *
Calculator *
Tape Recorder *

Requested Accommodations for Testing Extended Time
Out of Class
Distraction Reduced Area
No Optical Mark Recognition (OMR) sheets, i.e. Scantron®
Reader
Scribe
Alternative Format
Calculator *

Request accommodations not listed.

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** After completing this form, you will receive a confirmation email with instructions on setting an appointment and guidelines for documentation.