Disability Resource Center

Name*

First Last

Student ID*

Student Email*

Professor Name*

First Last

Professor Email*

Course Code and Name

Semester

Prior to completing this form, refer to the Modified Attendance as an Accommodation guidelines in the Application Process for Accessing Accommodations.

Impact

How might the student’s disability impact his/her course attendance/participation?

How often does the disability typically impact the student’s ability to attend class/complete assignments?

Every day
Once a week
2 to 3 times a week
Once a month
2 to 3 times a month
Less than once a month

What is the typical duration of an absence/impact due to the student’s disability?

Multiple Hours a day
Once a week
2 to 3 times a week
Once a month
2 to 3 times a month

What situations/conditions impact the student’s ability to attend class?

Please Include any of the following factors: time of day, weather conditions. severe symptoms of flare ups of disabling condition, etc.

Part 2: Modifications

Attendance Policy for Course:

State existing policy.

Modifications Appropriate for this Course:

The method and timing of notification of absences to professor

The method and timing for making up any materials, exams, assignments, etc. missed due to the disability.

Student Signature*

Type your name to indicate your signature and approval of the form data above.

Faculty Signature*

Type your name to indicate your signature and approval of the form data above.