Application for Student Accommodations

General Information

The Southern University System is committed to ensuring that all information and communication pertaining to a student’s disability is maintained as confidential as required by law. Therefore, all documentation obtained as part of an accommodation request, including medical and other relevant information, shall be maintained as confidential records, separate from the student’s academic record, and subject to disclosure only as allowed by law or with the student’s permission.

If you have any questions, please reach out to your respective Disability Services Coordinator.

Southern University and A&M College

Jada J. Netters, M.A., SSP

subr.services@sus.edu

(P) 225-771-3546

Southern University Law Center

Dorothy Parker, B.S., M.S., ADAC

dparker@sulc.edu

(P) 225-771-3117 ext. 276

Southern University at New Orleans

Sheridan X. Cooper, J.D.

ods@suno.edu

(P) 504-286-5362

Southern University at Shreveport

Anjelica Hart, Ed.D.

ahart@susla.edu

(P) 318-670-9367

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Campus Name(Required):

This field is required.

Student Information

Student's Name (First and Last)

Select Gender

Banner (U) Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Student Responsbilities

As the Student, I understand the following:

Accommodations are not retroactive, and the University is not obligated to provide accommodations until the application process has been completed and accommodations have been officially approved by the Disability Services Coordinator.
It is my responsibility to self-disclose the presence of a disability to Disability Services to be eligible for accommodations through Disability Services.
It is my responsibility to request accommodations from Disability Services in advance of the need each semester.
It is my responsibility to self-advocate and communicate with faculty and staff as it relates to my disability and accommodations. This includes meeting with my professors to discuss the accommodations for each course.
It is my responsibility to routinely check my University email.
It is my responsibility to participate in the intake appointment with the Disability Services Coordinator after submitting this application.
It is my responsibility to follow the procedures for requesting and accessing specific accommodations.
It is my responsibility to meet the same essential standards as students without disabilities in my academic program and courses. Essential standards include academic, behavioral, performance, and technical standards.
It is my responsibility to report any challenges related to approved accommodations to the Disability Services Coordinator or ADA Coordinator as soon as is reasonably possible to address the challenge and avoid delays in accessing the accommodations.
It is my responsibility to follow all policies and procedures relating to Disability Services.
Each semester in which I am requesting accommodations through Disability Services, I must submit the following to Disability Services: (a) Application for Accommodations; (b) Complete course schedule; (c) Paid fee bill.
If I qualify for testing in the Disability Services testing center, it is my responsibility to schedule the exam at least three (3) business days prior to the exam with the Disability Services Coordinator and my professor.
If I qualify for the accommodation of recording lectures, I understand that I may not share the recorded lecture with other people without consent from the lecturer. I further understand that I shall no longer be eligible for this accommodation if I have been found to have shared a recorded lecture without the lecturer’s consent.
If I check out any equipment from Disability Services, it is my responsibility to ensure the equipment is neither lost, damaged, nor unreturned. I will be responsible for the current replacement or repair cost, which will be reflected on my student financial account.

Do you understand the aforementioned Student Responsibilities.(Required)

Yes

This field is required.

Semester Accommodations Being Requested(Required)

Fall Spring Summer

This field is required.

Major(Required) This field is required.

Student Organizations This field is required.

Residency(Required)

In-state student that lives on-campus In state student that lives off-campus Out-of-state student that lives on-campus Out-of-state student that lives off-campus

This field is required.

Do you receive third-party billing?(Required)

Yes No

This field is required.

If you receive third-party billing, list third-party vendor: This field is required.

Are you a client of Louisiana Rehabilitation Services?(Required)

Yes No

This field is required.

If you are a client of Louisiana Rehabilitation Services, list your case manager. This field is required.

Are you a veteran?(Required)

Yes No

This field is required.

Are you residing in residential housing?(Required)

Yes No

This field is required.

If you are residing in residential housing, are you requesting an emotional support animal?(Required)

Yes No N/A

This field is required.

Did you receive accommodations through Disability Services last semester?(Required)

Yes No

This field is required.

Emergency Contact Name (First and Last)(Required) This field is required.

Emergency Contact Relationship(Required) This field is required.

Emergency Contact Email(Required) This field is required.

Emergency Contact Phone Number(Required) This field is required.

Do you grant Disability Services permission to speak with your emergency contact regarding your records, including any accommodations, housed within Disability Services? This is a waiver of your rights under the Family Educational Rights and Privacy Act (FERPA).(Required)

Yes No

This field is required.

Nature of Request(Required)

Disability Temporary Disability English-Second Language (ESL) Pregnant and Parenting

You must make at least one selection.

Nature of Disability(Required)

Sensory Disability (e.g., hearing impairment, visual impairment, etc.) Learning Disability Physical/Medical Disability Psychological/Mental Health Disability Attention Deficit Hyperactivity Disorder (ADHD) Other

You must make at least one selection.

Please describe your diagnosed disability(ies), and state your date of most recent diagnosis. (If this is a renewal, please indicate "Renewal" below.)(Required) This field is required.

Please describe how your disability affects you both outside and inside the classroom, including testing and studying situations. (If this is a renewal, please indicate "Renewal" below.)(Required) This field is required.

List the names and contact information of the medical professional(s) treating the disabilities stated in this application. (If this is a renewal, please indicate "Renewal" below.)(Required) This field is required.

List any accommodations previously received.(Required) This field is required.

Supporting Documentation

Please provide any supporting documentation for your request with this application. If additional documentation is needed, Disability Services will contact you. Please note that any medical documentation, testing, evaluations, assessments, etc. must be within three (3) years of the start of the semester in which you are applying for accommodations. If this is a renewal request for accommodations, the only supporting documentation that is needed are your complete course schedule and paid fee bill. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

General Information

Student Information

Supporting Documentation

Submission