Disability Services

Instructors: Only students PRE-APPROVED by the Office of Disability Services are eligible for accommodations.

Please fill out the form completely to ensure proper testing procedures are followed.

Instructor's Information Full Name:

E-mail Address: (must be @svsu.edu)

Phone Number:

Office Number: (e.g. Wickes 361)

Student's Information Full Name:

Course / Test Information Course Number: (e.g. Psych 100)

Date test must be taken by: (e.g. 05/23/01)

How much time does the class receive: (e.g. 60 minutes)

Choose One:

Mail back to instructor Instructor will Pick Up

Student May Use:(Check all that apply)

Open Book:		Calculator:		Keyboard:
Scratch Paper:		Notes:

Additional Instructions: