DSS Accommodation Request

Student Information

Please enter your information

Enter the semester you are requesting DSS Accommodations Required *

Enter the semester you are requesting DSS Accommodations Fall Enter the semester you are requesting DSS Accommodations Spring Enter the semester you are requesting DSS Accommodations Summer Enter the semester you are requesting DSS Accommodations Winter

Enter the year you are requesting DSS accommodations Required *

First NameRequired *

Middle Initial

Last NameRequired *

BSU Student ID NumberRequired *

Pronouns

Last four of Social Security NumberRequired *

Student Email AddressRequired *

Please use your university issued email address

Personal Email AddressRequired *

Primary Phone NumberRequired *

Secondary Phone Number

Street Address

City

State or Province

Zip or Postal Code

Armed Forces StatusRequired *

Armed Forces Status Reserves Armed Forces Status Retired Armed Forces Status Veteran Dependent/Survivor Armed Forces Status N/A

Are you an international student?Required *

Are you an international student? Yes Are you an international student? No

Enrollment StatusRequired *

Have you received accommodations from the DSS office before?Required *

Have you received accommodations from the DSS office before? Yes Have you received accommodations from the DSS office before? No

List of previous accommodations

Testing Accommodations Academic Accommodations Housing Accommodations

Specific Accommodation Information

Disability Information (Indicate all that apply)Required *

If other, please specify

If temporary, please specify the temporary condition

If the requested accommodation is in a temporary condition, please provide the anticipated duration

Requested Accommodations

List other accommodationsRequired *

Do you need assistance during emergencies and/or fire drills?Required *

Do you need assistance during emergencies and/or fire drills? Yes Do you need assistance during emergencies and/or fire drills? No

If yes, specify the type of assistance below

Housing Accommodation

This is NOT a housing application.

Are you requesting Housing Accommodations?

Are you requesting Housing Accommodations? Yes Are you requesting Housing Accommodations? No

Please indicate the nature of your housing request. (Check all that apply.)

Medical Physical Dining Needs Mental Health

Specific Housing Request: (Please check all that apply).

Close proximity to bathroom Elevator Furniture modification Grab bar in bathroom Modified toilet Personal care attendant Pivate bathroom Roll-in shower Space for medical equipment Visual alarms Wheelchair Access Access to a refrigerator Service animal Emotional Support Animal Other

Other Housing Request

Medical Needs:

Single, single bathroom in a suite Double Occupancy Bedroom in a suite First Floor Limit Medical access to kitchen Other Single, dorm style

Other Medical Needs

Dining Needs:

Access to shared kitchen access to private kitchen excemption from dining

Other needs: Please specify other needs otherwise indicated above

Please describe how the requested accommodations are necessary to allow you to access BSU housing.

Please explain if there are any alternatives to the above-mentioned accommodation.Required *

Would you like to request a Personal Care Attendant?

Would you like to request a Personal Care Attendant? Yes Would you like to request a Personal Care Attendant? No

Would you like to request a Service Animal?

(This is not a Emotional Support Animal)

Policy: VI - 1.12 - Policy on Service and Emotional Support Animals

Would you like to request a Service Animal? Yes Would you like to request a Service Animal? No

Would you like to request a Emotional Support Animal?

(This is not a Service Animal)

Policy: VI - 1.12 - Policy on Service and Emotional Support Animals

Would you like to request a Emotional Support Animal? Yes Would you like to request a Emotional Support Animal? No

Would you like a referral to Counseling Services?Required *

Would you like a referral to Counseling Services? Yes Would you like a referral to Counseling Services? No

Upload supporting document(s)Required *

Drop files here to upload