Request for Accommodations -

Student Request for Accommodation Eligibility

Disability Accommodations & Success Strategies (DASS)

Students should complete this form and submit it electronically to be considered for accommodation eligibility. Because responses will help us better serve your learning needs, we require that only students complete this form.

First Name:
Last Name:
Student ID#:
Today's Date:
Cell Phone Number:
Email Address:
SMU Academic Advisor:
Anticipated Graduation Date:
For which semester/year are you seeking accommodations?
Enrolled as:	First-Year Undergraduate Upper-Class Undergraduate Graduate Transfer Transferred from: Non-Degree/Other
Please identify your primary disability	ADHD Learning Disability Physical/Medical Hearing Impairment Visual Impairment Mental Health Disorder Other If other, please describe:
Please identify your secondary disability	ADHD Learning Disability Physical/Medical Hearing Impairment Visual Impairment Mental Health Disorder Other If other, please describe:
When were you first diagnosed (year, age or grade)?
How does your disability affect your academic and non-academic life now? Please be specific and give examples.
Are you comfortable discussing your disability with others? Please explain why or why not.
List any medications you are currently taking related to your disability and their side effects.
Describe any injuries or health concerns which affect your school performance.
List any approved accommodations you regularly used in your previous school.
Describe any grades repeated or course substitutions received in the past and how they relate to your disability.
Describe any support services and/or outside help you received in your previous school. Please include frequency.
What services or accommodations do you hope to receive through DASS?
Please rate how significantly your diagnosed condition affects the skills at right. If there is an impact, please tell us how you have managed those skills so far.	Concentrating No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Listening No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Communicating No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Organization No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Managing Distractions No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Timely Submission of Assignments No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Attending Class Regularly No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Making & Keeping Appointments No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Managing Stress No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Reading No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Writing Essays & Papers No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Taking Notes No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Spelling No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Math Skills No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Processing Speed No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Memory No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Walking No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability Sleeping No Impact Moderate Impact Significant Impact Describe strategies you have used to overcome challenges with this skill/ability
What skills do you feel you need to improve in order to succeed at SMU?
Is there anything else you would like to share about yourself not covered here or in the medical documentation you submit?

By submitting this form I acknowledge that: (1) only the student/applicant has filled out this form; (2) this application will not be processed until pertinent documentation of disability has also been provided; (3) the DASS documentation review committee will consider the accommodations as requested on this form; and (4) I authorize DASS and individuals providing information in the documentation to consult as part of the review process.

In addition to this request form, please submit your documentation in one of these 3 ways:

Email to dass@smu.edu.
Fax to 214-768-1255
Mail to:
Southern Methodist University
Altshuler Learning Enhancement Center
Disability Accommodations and Success Strategies
PO Box 750201
Dallas, TX
75275-0201

Student Request for Accommodation Eligibility

Disability Accommodations & Success Strategies (DASS)

Concentrating

Listening

Communicating

Organization

Managing Distractions

Timely Submission of Assignments

Attending Class Regularly

Making & Keeping Appointments

Managing Stress

Reading

Writing Essays & Papers

Taking Notes

Spelling

Math Skills

Processing Speed

Memory

Walking

Sleeping