Request for Accommodations
Semester
 Fall
1128
 Spring
1132
 Summer 1126
(Summer Session # __ )
Please read both pages.
NAME:
UID NUMBER:
ASSOCIATION DEAN OR 1ST YEAR
RESIDENCE:
SCHOOL:
EMAIL:
 CLAS
 ARCH
 SEAS
 NURSING
 CURRY  TRANSFER
 COMM (CC: LEONARD)
 OTHER ________________________________________
AGREEMENT OF UNDERSTANDING:
 By checking this box I understand the following: My faculty memos will be completed in approximately
5 to 10 business days after I have submitted this request. I am then responsible for picking them up
and personally delivering them to faculty. It is recommended that I deliver the memos the first week
after I pick them up. Today’s Date (MM/DD/YY):_____________
Accommodation Requests
Please check only your approved accommodations that you want for the current semester.
IN CLASS
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Peer Notes
Interpreter
Captioning
FM System
Alternate Text Formats
Permission to Record Class
Preferential Seating
Unavoidable Absences
Other __________________________________
__________________________________
EXAMS
 Extended time (select one below)
 1.25 (time-and-a-quarter)
 1.5 (time-and-a-half)
 2.0 (double time)
 Alternate format (should be discussed)
 Reduced distraction environment
 Scribes
 Word processing
Other______________________(e.g. private room)
PLEASE LIST COURSE INFORMATION BELOW
SEPARATELY LIST DISCUSSION/LAB SECTIONS
Course Information
(Please follow the boldfaced example below and note if you have any exceptions.)
COURSE
MNEMONIC
COURSE
NUMBER
SECTION NUMBER
PROFESSOR OR TA
COMMENTS
ANTH
2190
0001
George Mentore
Just Notes &
Extended Time
Complete this section only if requesting a Foreign Language Memo.
COURSE MNEMONIC
FOR LNEC STAFF USE ONLY
LNEC FORMS: GREEN SHEET REV: 07/2012
COURSE NUMBER
Date Memos Prepared:
SECTION NUMBER
Staff Initials:
Submit
PROFESSOR OR TA
Ticket Number: