Initial Information Form

What is your diagnosed disability?Required *

[select]ADD/ADHD Autism Spectrum Disorder Blind/Low Vision Deaf/Hard of Hearing Learning Disability Medical Mobility Other Psychological/Mental Health Temporary clear

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Do you use assistive technology?Required *

Do you use assistive technology? Yes Do you use assistive technology? No

Please identify the academic modification(s) that you are requestingRequired *

Check all that apply

Attendance modifications Rescheduling tests or exams Opportunity to make up missed clinical/lab hours Incomplete grade/course extension Limited exposure to potentially dangerous substances (e.g., lab or clinical) Seating change/options Access to food/drink during class Frequent restroom use Limited lifting Limited standing Breaks to use lactation room Other

Do you authorize IE to communicate with your instructors? You will be copied on all emails.Required *

Do you authorize IE to communicate with your instructors? You will be copied on all emails. Yes Do you authorize IE to communicate with your instructors? You will be copied on all emails. No