Public Accommodation Request

* indicates a required field

Student Information

Please enter your information below. Supporting documentation MUST be attached to the application at the time of submission. You will be prevented from submitting this request without the attached documentation.

Documentation verifies your eligibility for accommodations under Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, and the ADA Amendments Act. Documentation commonly submitted includes, but is not limited to, IEPs and/or letters from treating physician/clinician. All documentation submitted is considered confidential.

Documentation must be in .pdf or .doc file format.

In the event that you may not have access to a scanner or fax, you can utilize a free app that converts images into pdf files (eg., CamScanner).

Student IDRequired *

First NameRequired *

Middle Name

Last NameRequired *

Sex

PronounsRequired *

If you would prefer not to answer, please just type in N/A.

Date of BirthRequired *

Student Phone NumberRequired *

Please format as (xxx) xxx-xxxx

ESU Email ONLYRequired *

Please use your university issued email address

Permanent (Home) Address

Housing

Major

Minor

ClassificationRequired *

{"display_name":"Classification","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}

Date you will be attending ESU

Transfer StudentRequired *

Transfer Student Yes Transfer Student No

If yes, from where:

International StudentRequired *

International Student Yes International Student No

US VeteranRequired *

US Veteran Yes US Veteran No

If yes, dates of service: From

Dates of service to:

Are you a client of:Required *

The Veteran Administration of Vocational Rehabilitation?
The State Vocational Rehabilitation

What is your current disability diagnosis? Required *

Check appropriate category below.

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Have you received accommodations from OASIS or the ESU Office of Disability Services in past semesters?Required *

Have you received accommodations from OASIS or the ESU Office of Disability Services in past semesters? Yes Have you received accommodations from OASIS or the ESU Office of Disability Services in past semesters? No

Date of previously provided accommodations

What type of accommodation are you requesting? You will be able to apply for both academic and housing accommodations in this form.

I am requesting Academic Accommodations.Required *

The specific type of academic accommodation(s) you are requesting will be addressed below.

I am requesting Academic Accommodations. Yes I am requesting Academic Accommodations. No

Describe how your current disability impacts you at school:Required *

Describe how your current disability impacts you at work:

Describe how your current disability impacts you socially/personally:

Check the areas affected by your current disability:

Math
Reading
Writing
Concentration
Time Management
Processing
Memory/Recall
Social
Organization
Attention
Reasoning

Describe your strengths, weaknesses, and special interests:

What type of school did you attend?Required *

High School Name

Did you have an IEP, 504 plan, or some other school-based support?

Did you have an IEP, 504 plan, or some other school-based support? Yes Did you have an IEP, 504 plan, or some other school-based support? No

What were your grades or grade point average (GPA) in high school or other undergraduate studies?

Approximately how many hours a week do you spend studying/preparing for school?

What accommodations worked in the past? (Check all that apply)

Note taker
Audio recording of lectures
Exams taken on computer
Scribe for exams
Reader for exams
Exams administered in a reduced distraction setting
Extended time on tests - up to 100%
Extended time on tests - up to 50%
Alternative format for printed material
Calculator

Did you use any forms of assistive technology?

Did you use any forms of assistive technology? Yes Did you use any forms of assistive technology? No

Type of assistive technology used

Did you use any types of alternative communication methods?

Did you use any types of alternative communication methods? Yes Did you use any types of alternative communication methods? No

Type of alternative communication used

Are you taking any medication to manage the impacts of your disability?

Are you taking any medication to manage the impacts of your disability? Yes Are you taking any medication to manage the impacts of your disability? No

Please describe, including if effective or ineffective

Have you participated in therapeutic services to manage the impacts of your condition?

(therapy, coaching, support services, etc.)

Have you participated in therapeutic services to manage the impacts of your condition? Yes Have you participated in therapeutic services to manage the impacts of your condition? No

Please describe, including if these were effective or ineffective

I am requesting Housing AccommodationsRequired *

The specific type of housing accommodation(s) you are requesting will be addressed below.

I am requesting Housing Accommodations Yes I am requesting Housing Accommodations No

What kind of housing accommodation(s)/environmental access are you requesting? (please check all that apply)Required *

Air Conditioning
Location of room
Other
Single room

I am requesting to have an emotional support animal Required *

I am requesting to have an emotional support animal Yes I am requesting to have an emotional support animal No

Describe how the emotional support animal has been historically necessary to alleviate symptoms of your disability. Required *

Please be specific and use examples

Has the animal ever been aggressive toward or bitten you or another individual or animal? Required *

Has the animal ever been aggressive toward or bitten you or another individual or animal? Yes Has the animal ever been aggressive toward or bitten you or another individual or animal? No

What is the animal's name? Required *

What is the species/breed of the animal?Required *

Animal's SexRequired *

Animal color: Required *

Age of animal Required *

Animal weightRequired *

Please select the residence in which you will be living. Required *

Please select the residence in which you will be living. Sycamore Suites
Please select the residence in which you will be living. University Ridge
Please select the residence in which you will be living. University Apartments
Please select the residence in which you will be living. Shawnee Hall
Please select the residence in which you will be living. Minsi Hall
Please select the residence in which you will be living. Linden Hall
Please select the residence in which you will be living. Lenape Hall
Please select the residence in which you will be living. Laurel Hall
Please select the residence in which you will be living. Hemlock Suites
Please select the residence in which you will be living. Hawthorn Suites
Please select the residence in which you will be living. Unknown

I understand: (Please check each item as it pertains to your application)Required *

I understand that housing requests must be submitted to OASIS by May 15th.
My accommodation request must be reasonable and supported by documentation.
I know that I must follow the procedure to receive this accommodation.
The Office of Accessible Services Individualized for Students reserves the right to request an intake interview to provide this accommodation.
Approved housing accommodations are provided on a first-come, first-serve basis when submitted by May 15th.
All regular housing procedures must be followed (e.g. completed application, deposit, contract, etc.).

I (the student) must contact the Office of Residence Life and Housing (570-422-3191) with any questions about this accommodation.

Release of Information

I authorize the Office of Accessible Services Individualized for Students and Residence Life and Housing to share information from my records with others as deemed appropriate.

Yes

I am requesting Temporary Accommodations.Required *

Types of temporary accommodation(s) are parking requests and having a car on campus, for example.

I am requesting Temporary Accommodations. Yes I am requesting Temporary Accommodations. No

What form of temporary accommodation(s) are you requesting?

Documentation Guidelines of a Temporary Condition for Diagnosing and/or Treating Professionals

In order to provide students with appropriate accommodations, documentation is beneficial in determining eligibility and accommodations. Documentation provides a valuable tool in the collaborative process of providing access to the educational process. Documentation should:

1. Clearly state the condition that meets the criteria for a disability under the law based on the current diagnostic standards.

2. Describe the current impact resulting from the disability or disabilities. Please consider expected changes in the impact of the condition(s) over time and in a different environment.

3. Clearly state the length of time the temporary disabling condition may require the requested accommodation(s).

4. Include educational, developmental, and medical history relevant to the disability for which accommodations and services are being requested.

5. Provide the reason (temporary educational or environmental accommodation requests) for submitting the documentation.

6. Include the professional's name, title (including licenses and credentials that indicate the qualification to describe and diagnose disability), date of evaluation, and report typed with signature.

I understand that to be eligible for accommodations at East Stroudsburg University I must provide this completed form and participate in an intake interview with a disabilities specialist. I also understand that submitting supporting documentation will assist the Office of Accessible Services Individualized for Students in providing me with appropriate accommodations. I authorize the Office of Accessible Services Individualized for Students faculty to share information from my records with other staff members in the Office of Accessible Services Individualized for Students and pertinent university departments as necessary until I sign the Release of Information Form during my intake interview.

Upload supporting document(s)Required *

Please submit documentation as either a .pdf or .doc file. No other types of file formats will be accepted. In the event that you may not have access to a scanner or fax, you can utilize a free app that converts images into pdf files (eg., CamScanner).

Public Accommodation Request

Student Information

What type of accommodation are you requesting? You will be able to apply for both academic and housing accommodations in this form.

Document Information