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Request an Accommodation

Use this form to request academic, dining or housing accommodations. To view the process for each type of accommodation, see the Accommodation Guidelines for each. If you have questions, contact CAE at 563-387-1270 or [email protected]

* = required field

Contact Information

Full Name*

Birth date (MM/DD/YYYY)

Student I.D. Number*

Email Address*

Class Status*

Expected Graduation Date

Disability Information

What Brings You to Disability Services?

	I am looking for information - I want to know what my options are.
	I am looking for possible accommodations.
	Other (Specify below.)

Additional Note

Description of Disability

Additional Note or Comment

Accommodation Request

What accommodations are you looking for?

Additional Note or Comment

Please note: Accommodations will be discussed in person in a meeting with the Disability Services staff member. Please call the Center for Academic Enrichment to set up an appointment at 563-387-1270.

I understand I must meet with Disability Services and provide documentation of my disability in order to be eligible to receive accommodations. I certify that the above information provided is accurate. Please reply with "Yes" in the field below to agree to this statement.*

Tarbabypre

(Please don't fill in this field.)

Tarbaby

(Please don't fill in this field.)

Noturl

(Please don't fill in this field.)

Antlion

(Please don't fill in this field.)

	Extended time
	Housing
	Course materials in alternate format
	Note-taking support
	Audio recording in class
	Other (please comment below)