Disability Services & Access (DSA) Form

Disability Serviced & Access (DSA) Facilitations

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

This form is intended for students who wish to request reasonable adjustments and support services due to a disability, medical condition, learning difficulty, or other health-related concern. The information provided will enable the Disability Services & Access Office to assess your needs and determine appropriate accommodations in accordance with institutional policies and relevant legislation. All information submitted will be treated confidentially and used solely for the purpose of facilitating equal access to your programme of study.

A. Student Information

File No.:*

Date:*

MM slash DD slash YYYY

First Name:*

Middle Name:

Last Name:*

Email:*

Phone No.:*

Address:*

Street Address City ZIP / Postal Code Country

B. Academic Information

Programme of Study:*

MSc Hospitality & Tourism

BSc Hotel Administration

Certificate Cruise Ship Hospitality Operations

Foundation Programme

Semester:*

Fall

Spring

Summer

Year:*

C. History

Previous Academic Institution:*

Date Attended From:*

MM slash DD slash YYYY

Date Attended To:*

MM slash DD slash YYYY

Previous Approved Disability Accommodation & Services:*

D. Disability Information

Select one or more disabilities:

Physical (Mobility) Disorder

Psychological

Chronic Medical Condition

Hyperactivity Disorder

Deaf/Diminished Hearing

Blind/Diminished Vision

Traumatic Brain Injury

Learning Disability

Attention Deficit Disorder

Other

Please specify:*

I. Please describe how your disability, medical condition, or learning difficulty impacts your academic performance and ability to meet the requirements of your programme. You may wish to refer to areas such as attending lectures, concentrating during classes, completing assignments, sitting examinations, participating in practical activities, meeting deadlines, managing workload, or any other academic obligations.

II. Please describe how your disability, medical condition, or learning difficulty affects your daily functioning outside of your academic responsibilities. You may wish to refer to aspects such as mobility, communication, personal care, time management, social interaction, managing stress or fatigue, or any other day-to-day activities that may be impacted.

III. Provide any information about your programme of study that you feel is important and relevant to your accommodation request. Please include any details about your programme that may influence your accommodation needs, such as laboratory work, practical training, industrial placements, fieldwork, group projects, presentations, clinical components, or specific assessment methods. You may also indicate any modules or academic requirements that you believe require particular consideration in relation to your disability.

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

Disability:

Date of Diagnosis:

List the difficulties you may experience in writing, concentrating or remembering information that may be related to your disability (ex. reading, completing tasks).

Part 2 - Deaf or Hard of Hearing

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.)

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

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

Please indicate which of the following apply to you:

Motorized Wheelchair/Scooter

Prosthesis

Manual Wheelchair

Other

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

Easily tire when walking long distances

Difficulty walking up/down the stairs

Difficulty taking notes in class

Difficulty writing

Utilizing Assistive Technology

Academic Difficulties:

Please provide a brief statement outlining any academic difficulties you experience as a result of the above.

Part 4 - Visual Disability or Blind Please indicate if any apply

Visual Activity (If Applicable)

Left Eye

Right Eye

Degree of Blindness:

Total

Light Perception

Form Perception

Mobility Aids:

Cane

Service Animal

Other

Please specify:*

Do you use assistive technology? Please specify:

Do you use alternate format reading materials?

Yes

Please specify:*

V. Disability Documentation Please provide details of the medical or professional documentation you will be submitting in support of your request (e.g., medical certificate, diagnostic assessment, psychologist’s report, specialist evaluation). Kindly ensure that all documentation complies with Casa College Regulations and clearly outlines your diagnosis, the functional impact on your studies, and any recommended accommodations. Please note that it is the student’s responsibility to submit complete and valid documentation for review.

Name of Provider:

Date of Documentation:

DD slash MM slash YYYY

Type of Documentation:

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

Disability Verification Form

Letter from previous Educational Organisation confirming approved disability accommodations

Letter from Treatment Provider

Other

If other, please specify:

VI. Accommodation & Services Please specify the accommodations you are requesting. The Disability Services & Access Office will review your request in consideration of the nature and functional impact of your disability, as outlined in your supporting documentation and the information provided in this form, together with the academic and professional requirements of your programme of study. Approval of accommodations is subject to institutional regulations and may be granted where deemed reasonable and appropriate.

Testing Accommodation:

Extended time for in-class exams and quizzes

Smaller proctored environment

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

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

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

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.

Consent*

I agree to the Privacy Policy*

Disability Serviced & Access (DSA) Facilitations

A. Student Information

B. Academic Information

C. History

D. Disability Information

Casa College

PROGRAMMES

USEFUL LINKS

SUBSCRIBE TO OUR NEWSLETTER