Title

504 QUESTIONNAIRE

Section 504 of the Vocational Rehabilitation Act of 1973, provides for the elimination of discrimination due to specific documented needs. All new students must submit Section A and Section C. Section B of this questionnaire provides an opportunity to disclose information about needs (optional).

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SECTION A:

Name:

Home Address:

City: State: Zip Code:

Telephone:

Student ID Number:

Student E-Mail Address:

When will you begin attending Ferrum College: Year Fall SemesterSpring Semester

I do not have a disability or I do not wish to disclose information. (If choosing this option, after completing Section A, please sign at the bottom of the page, and mail this form to Professor Nancy Beach at the address provided below.)

I have documentation of a disability and I am mailing a copy of professional documentation to the address below. I understand I must meet with the service provider to request the specific services needed; they are not provided automatically.

SECTION B (optional). Complete this section only if you will be asking for services. You must send documentation now, and schedule a meeting to request the support you need; it will not be provided automatically.

Academic Support (ex: extended time for tests, quieter area for tests, etc.)	Special Housing, Dietary or Facilities (ex: wheelchair accessible, automatic doors, gluten sensitivity, etc.)
Nancy S. Beach Office of Academic Accessibility (OAA) Director P.O. Box 1000 Ferrum College Ferrum, Virginia 24088 For questions, you may send email to: nbeach@ferrum.edu	Vanessa Stone P.O. Box 1000 Ferrum College Ferrum, Virginia 24088 For questions, you may send email to: vstone@ferrum.edu
Please note: Please send your information to the correct office, as described above, to avoid a delay in the processing of your request.

Guidelines: Documentation of disability should consist of an evaluation by an appropriate professional and include: 1) a clear statement of the diagnosis; 2) the basis for the diagnosis; and 3) the current impact of the disability as it relates to the accommodation request
As appropriate to the disability, the documentation should include the following elements:
   1. A diagnostic statement identifying the disability, date of the most current diagnostic evaluation, and the date of the original diagnosis.
   2. A description of the diagnostic tests, methods, and/or criteria used, including specific test results (including standardized testing scores) and the examiner's narrative interpretation.
   3. A description of the current functional impact of the disability. This may be in the form of an examiner's narrative, and/or an interview, but must have a rational relationship to diagnostic assessments. For learning disabilities, current documentation is defined using adult norms.
   4. A statement indicating treatments, medications, or assistive devices/services currently prescribed or in use, with a description of the mediating effects and potential side effects from such treatments.
   5. A description of the expected progression or stability of the impact of the disability over time, particularly the next five years.
   6. A history of previous accommodations and their impact.
   7. The credentials of the diagnosing professional(s), if not clear from the letterhead or other forms. Please note that the diagnosing professional(s) shall not be family members or others with a close personal relationship to the individual being evaluated.
   • Documentation prepared for specific non-educational venues (e.g., Social Security Administration or Department of Veterans’ Affairs, etc.) may not meet the criteria outlined above.
   IEP or 504 plans may not be considered sufficient documentation unless accompanied by a current and complete evaluation.

SECTION C:

Submission of this electronic form constitutes your signature Date: