Housing Accommodation Request Form. Section A (Applies to All Students Submitting Housing Accommodation Requests)
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1 where gret minds get to work Office of Disbility Resources University of Mry Wshington Emil: Housing Accommodtion Request Form Prt I To be completed by Student Section A (Applies to All Students Submitting Housing Accommodtion Requests) Student Nme: UMW ID: Permnent Address: Are you living on cmpus? Yes No If so, where? Student Phone: Wht ws the first yer you ttended UMW? Wht is your current clss stnding (e.g., freshmn) Other thn the provider completing this form, re you connected with ny other provider(s) for the indicted dignosis(es)? Yes No If so, plese include the provider(s) nme, title, nd scope of prctice: Section B Is this request previously pproved? Yes No Section C - For Emotionl Support Animl (ESA) Request Only Proposed Emotionl Support Animl Nme: Type of Animl: Age of Animl:
2 where gret minds get to work Office of Disbility Resources University of Mry Wshington Emil: Section D (Applies to All Students Submitting Housing Accommodtion Requests) Requested Accommodtion(s): Plese stte the disbility(ies), provide description of the disbility(ies), nd provide n explntion of your disbility-relted need(s) for the ccommodtion(s) requested: By submitting this request, I m giving my consent for ll prties of the housing committee to discuss my current needs s relted to my housing request. Student Signture Dte
3 ~,111 UNIVERSITY OF where gret minds get to work Office of Disbility Resources University of Mry Wshington Emil: Student Nme: Prt II To be completed by Helthcre Professionl/Licensed Provider: This form should be completed by licensed provider nd/or helthcre professionl who is ble to fully nswer the questions below nd hs knowledge of the student s condition nd its impct on bility to perform mjor life ctivity. A Mjor life ctivities include, but re not limited to: cring for oneself, performing mnul tsks, seeing, hering, eting, sleeping, wlking, stnding, lifting, bending, speking, brething, lerning, reding, concentrting, thinking, communicting, nd working. The Housing Committee requires complete response to ll of the questions below in order to mke determintion on the student s request(s). Incomplete responses will hve significnt impct on the bility of the Housing Committee to mke determintion on the student s request. The prcticl limittions of our housing rrngements mke it necessry to crefully consider the impct of ll student requests on the student nd the cmpus community when determining resonble ccommodtions. Section A (Applies to All Students Submitting Housing Accommodtion Requests) The term disbility mens with respect to n individul who hs: 1. A physicl or mentl impirment tht substntilly limits one more mjor life ctivities of such individul: 2. A record of such n impirment; or 3. Being regrded s hving such n impirment 4. Informtion provided will become prt of the student record subject to the Fmily Eduction Rights nd Privcy Act of 1974 (FERPA) nd my be relesed to the student on their written request. Does the student hve disbility under this definition? Yes No
4 where gret minds get to work Office of Disbility Resources University of Mry Wshington Emil: Plese stte the student s disbility(ies), identify the student s impirment(s), nd describe how ech impirment substntilly limits his/her bility to perform mjor life ctivity: Plese identify if the student is using ny mesure (e.g., prescriptions, tretment, therpy, etc.) tht mitigtes the limittions cused by his/her impirment nd, if so, if the mitigting mesure(s) elimintes the substntil limittions. Expected durtion, stbility, or progression of the condition (if known): How long hve you been working with the student regrding this dignosis or impirment? Plese explin how the ccommodtion is necessry for the resident to use nd enjoy UMW housing s compred to person without disbility. Plese identify ny other ccommodtion tht my be eqully effective in llowing the resident to ccess UMW housing.
5 ~,111 UNIVERSITY OF where gret minds get to work Section B - For Emotionl Support Animl (ESA) Request Only Office of Disbility Resources University of Mry Wshington Emil: odr@umw.edu Is this n niml tht you specificlly prescribed s prt of tretment pln for the student? Wht symptoms will be reduced by hving this specific niml? Is there evidence tht n ESA hs helped this student in the pst or currently? In your opinion, how importnt is it for the student s well-being tht the ESA be in residence on cmpus? Wht consequences, in terms of disbility symptomology, my result if the ccommodtion is not pproved?
6 where gret minds get to work Office of Disbility Resources University of Mry Wshington Emil: Section C - Helthcre Professionl/Licensed Provider Informtion nd Credentils (Applies to All Students Submitting Housing Accommodtion Requests) Informtion provided will become prt of the student record subject to the Fmily Eduction Rights nd Privcy Act of 1974 (FERPA) nd my be relesed to the student on their written request. Student Nme: Helthcre Professionl/Licensed Provider Nme (Print): Title: License/Certifiction #: Address: Phone: Emil Address: Signture: Dte: Thnk you for completing this form. If we need dditionl informtion, we my contct you using the informtion provided with the student s written consent. If you hve questions regrding this form or the housing ccommodtion process, plese cll the UMW Office of Disbility Resources t (540) *Form should be provided bck to the student in order to llow them to uplod the document to their Accommodte Portl.
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