Delgado Community College
Office of Disability Services
Accommodation Referral Form
Name: ________________________________________ College Wide ID#: _________________
Address: _____________________________________________________________________________
Phone#: ____________________________ Email Address: ________________________
I hereby give consent for my clinician to disclose my medical/clinical evaluation for purposes of receiving reasonable accommodations.
Student Signature: ___________________________________________ Date: _________________
Please have your clinician complete below:
Primary Disability: _____________________________________________________________________
Secondary Disability: __________________________________________________________________
Limitations: __________________________________________________________________________
_____________________________________________________________________________________
Is this individual wheelchair bond? ___ yes ___ no
Accommodation Type:
___ Preferential Seating ___ Distraction-Free Environment
___ Extended Time (Test Only) ___ Use of Tape Recorder
___ Extended Time (Tests and Assignments) ___ Frequent Breaks
___ Reader ___ Assistive Technology
___ Oral Testing ___ Calculator
___ Interpreter ___ Stenographer
___ Note-taker ___ Assistive Listening Device
___ Scribe ___ Consideration for Frequent Absences
___ Alternative Test Format: __ No scantron __ Enlarge Print __ Rephrasing of Test Questions
Please attach supportive documentation (medical eval, psychological eval, neuro-psychological eval, educational-psychological eval, etc.) with this form. Failure to attach supportive documentation can result in a delay of the student receiving reasonable accommodations. All documentation must be within 3 years. Handwritten notes or notes on a prescription pad are not acceptable documentation.
Clinician Signature: _______________________________________ Date: _________________
Should you have any questions or concerns please contact Amanda Hassan, Interim Disability Services Coordinator by phone at 504-671-5161 or by email ahassa@dcc.edu
or by fax: 504-483-4524.
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