Delgado Community College
1. Office of Disability Services
2. Accommodation Referral Form
  1. Please have your clinician complete below:
  2. Accommodation Type:

Delgado Community College

Office of Disability Services

Accommodation Referral Form

Name: ________________________________________ LoLA 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 Joseph Williams Jr. Disability Services Coordinator by phone at 504-671-5161 or by email jwilli6@dcc.edu or by fax: 504-483-4524.

Form 1468/004 (11/19)