Disability Services & Access (DSA) Form

A. Student Information

File No:

First Name:

Middle Name:

Fill in only if applicable!

Last Name:

Fill in only if applicable!

Email:

Phone:

Current Address:

Street Address City ZIP / Postal Code Country

Home Address:

Street Address City ZIP / Postal Code Country

B. Academic Information

Programme of Study Attending:

BSc in Hotel Administration

Certificate in Cruise Ship Hospitality Operations

Semester:

Fall

Spring

Year:

C. Previous Educational Organisation(s) & Accommodation(s)

Previous Educational Organisation(s):

Dates Attended (From- To):

Previous Approved Disability Accommodation & Services:

D. Disability Information

Select one or more disabilities:

Physical (Mobility) Disorder

Psychological Problems

Chronic Medical Condition

Hyperactivity Disorder

Deaf/Diminished Hearing

Blind/Diminished Vision

Traumatic Brain Injury

Learning Disability

Attention Deficit

Other type of disability:

I. How does your disability affect your ability to complete your coursework or other programme of study requirements?

II. How does your disability affect you in your everyday life and daily activities?

III. Provide any information about your programme of study that you feel is important and relevant to your accommodation request.

IV. Only complete the sections below that apply to your documented disability/ies, then proceed to section VI.

Part 1 - Learning disability, AD/HD, Traumatic Brain Injury and Psychological Disabilities Mobility Disabilities

Part 2 - Deaf or Hard of Hearing

Part 3 - Chronic Medical Condition and Physical or other Mobility Disabilities

Part 4 - Visual Disability or Blind

Part 1

Kind of Disability:

Date of Diagnosis:

List the difficulties you may experience in writing, concentrating or remembering information that may be related to your disability (I.E. Reading, Completing Tasks).

Part 2

Do you wear hearing aids or cochlear impants?

Yes

If Yes, Select the one that apply:

Behind-the-ear hearing aids

Cochlear Implant-body

My device has telecoils

In-the-ear hearing aids

Worn processor

Cochlear implant-ear level processor

My device has an M-T micro telecoil switch

In-the-canal hearing aids

Do they have Direct Audio Input (DAI)?

Yes

Please choose your preferred method of communication:

Telephone (WhatApp, Viber etc.)

Skype

What types of other auxiliary aids have you used, if any:

What means of expression and receptive communication do you use?

Oral Communication

Speech Reading

Sign Language

Tick the ones that apply to you.

Part 3

Please, choose the ones that apply:

Motorized Wheelchair/Scooter

Prosthesis

Manual Wheelchair

Other:

Please specify!

If Prosthesis was selected, please specify:

Do you take the stairs on a regular basis? If so, how many stairs can you climb?

Do you experience any of the following?

Difficulty in standing for a long time

Getting easily tired when walking long distances

Difficulty walking up/down the stairs

Difficulty in taking notes in class

Difficulty in writing

Utilizing Assistive Technology

Academic Difficulties:

Please describe:

Part 4:

Visual Activity (If Applicable)

Left Eye

Right Eye

Degree of Blindness:

Total

Light Perception

Form Perception

Mobility Aids:

Cane

Service Animal

Other

If Other please specify:

Do you use assistive technology? Please specify:

Do you use alternate format reading materials?

Yes

If Yes, please specify:

V. Disability Documentation

Please provide information about the disability documentation you will be submitting to our office. Note that you are responsible to ensure that your documentation meets the Casa College Regulations.

Name of Provider:

Date of Documentation:

Type of Documentation:

Learning Disability, AD/HD, Psycho-Educational, or Neuropsychological evaluation

Disability Verification Form (Available on DS website)

Letter from previous Educational Organisation confirming approved disability accommodations

Letter from Treatment Provider

Other

If other, please specify:

VI. Accommodation & Services

Please specify what accommodations you request. Disability services will consider your request in light of your disability as described in your supporting documentation and other information provided to disability services, as well as the requirements of your programme of study.

Testing Accommodation:

Extended Time for In-Class Exams and Quizzes

Smaller Proctored Environemnt

Scriber for Exams (Answer Recorded/Written for Student)

Use of computer for Exams

"Stop the Clock" Rest Breaks: up to 15 minutes per hour of exam time

Other

If Other, please specify:

Classroom Accommodation:

Note-Taking Services

Permission to use laptop for note-taking in class

Permission to record lectures

Accessible classroom and furniture

Other

If Other, please specify:

Communication/Technology Accommodation:

Sign-Language Interpreters

Assistive Listening Devices (e.g. FM or Infrared systems)

Real Time Captioning (CART)

Captioned videos, podcasts, or other media

Audio Format

Other

If Other, please specify:

Please tick the appropriate box:

I do not request accommodations at the moment, but I would like to register given the changing nature of my disability.

I am not sure what I need - I would like to discuss this with someone.