Public Accommodation Request

Student Information

Please enter your information

Instructions

Please complete this form if you are requesting accommodations for the first time at NCCU.

If you already have approved accommodations and want to make modifications to those, please log in to Accommodate to submit a supplemental request.

If you are a prospective student that does not have an assigned Banner ID, please email sas@nccu.edu.

First NameRequired *

Last NameRequired *

Middle NameRequired *

Banner IDRequired *

If you are a prospective student that does not have an assigned Banner ID, please email sac@nccu.edu.

Date of BirthRequired *

NCCU EmailRequired *

Please use your university issued email address

Alternate Email

Phone NumberRequired *

Alternate Phone Number

Would you like to opt-in to receiving text messages from SAC?Required *

Please note that if you use T-Mobile you will not be able to opt-in to receiving text messages.

Would you like to opt-in to receiving text messages from SAC? Yes Would you like to opt-in to receiving text messages from SAC? No

Please confirm your cell phone numberRequired *

Please enter your 10-digit cell phone number.

Please select your mobile carrierRequired *

Please note that T-Mobile subscribers will not be able to opt-in to text messaging.

Academic Information

ClassificationRequired *

MajorRequired *

Enrollment StatusRequired *

Enrollment Status Undergraduate Student
Enrollment Status Graduate Student
Enrollment Status Transfer Student

Select your Graduate ProgramRequired *

Graduate Program TitleRequired *

Are you a student athlete?Required *

Are you a student athlete? Yes Are you a student athlete? No

What NCCU athletic teams are you part of?

Accessibility Specific Information

Instructions: There is much variability within each accessibility category, and therefore, the type of accommodations needed can vary significantly. Below, you will find descriptions of the various types of disabilities recognized in the United States. Student needs vary according to each individual. Therefore, it is important for the participating student to clarify the particular accommodations she or he requests

My specific disability or medical condition falls into the following category(ies)Required *

Attention Deficit/Hyperactivity Disorder (ADHD/ADD) Autism Spectrum Chronic Medical (i.e., sickle cell, lupus, cancer, etc.) Isolation and Quarantine Hearing Impairment Learning Disability Mobility Impairment Physical Impairment Psychological/Psychiatric (i.e., schizophrenia, bi-polar disorder, generalized anxiety disorder) Speech/Language Temporary (i.e., injury, minor surgery, pregnancy) Traumatic Brain Injury Visual Impairment Other Health Condition N/A

Explain the functional impact of the disability on your academic performance.Required *

If you have tried any medical or educational interventions to manage the diagnosed condition, please explain them and describe their impact. If there are situations when the diagnosed condition has no impact on your learning, describe that here as well.

Explain the functional impact of the disability on your activities of daily living.Required *

Please explain any limitations such as ability to get to and from class, participation in school activities, eating, exercise, etc.

Please list or describe the accommodations you're requesting.Required *

What semester are you requesting accommodations to begin?Required *

Did you receive any type of special educational services while in high school?:Required *

Did you receive any type of special educational services while in high school?: Yes Did you receive any type of special educational services while in high school?: No

Please specify the services:Required *

Did you receive any type of special accommodations at a previous college?Required *

Did you receive any type of special accommodations at a previous college? Yes Did you receive any type of special accommodations at a previous college? No

Are you a First-Generation college student? Required *

students whose parents (biological or adoptive) did not earn a degree from a four-year university. If your parent(s) attended college but did not graduate with a bachelor’s degree, you are still considered a first-generation college student.

Are you a First-Generation college student? Yes Are you a First-Generation college student? No

Do you currently receive or are you eligible to receive Pell Grant?Required *

Do you currently receive or are you eligible to receive Pell Grant? Yes Do you currently receive or are you eligible to receive Pell Grant? No

Please specify the accommodations:Required *

Are you a client of State/Federal Agency? (For example, Vocational Rehabilitation, VA, DBS, etc.)Required *

Are you a client of State/Federal Agency? (For example, Vocational Rehabilitation, VA, DBS, etc.) Yes Are you a client of State/Federal Agency? (For example, Vocational Rehabilitation, VA, DBS, etc.) No

If "Yes" to the above question, please specify the Agency Name, Contact/Counselor, and Contact Information.Required *

Agency Name; Contact/Counselor Name and Contact Information

Upload supporting document(s)Required *

Please upload any supporting documentation related to each disability to which you are requesting reasonable accommodations. To Review Our Documentation Guidelines click here

Permission for Release of InformationRequired *

I give permission for the Office of Student Disability Services to disclose information with specific faculty and staff at NCCU, as well as with those professionals who are rendering services, when deemed appropriate for the purposes of supporting my academic, personal and/or social needs while enrolled at NCCU.

Permission Granted

Public Accommodation Request

Student Information

Academic Information

Accessibility Specific Information

Document Information