Student Disability Center

Serving Students with Disabilities
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SDC Placement Exam Accommodation Request Form

If you have been determined eligible for SDC services, please complete the form below with as much detail as possible. After the form has been submitted, your request will be processed and you will be contacted if your accommodations are approved. You will then need to come in to the Student Disability Center to sign the paper copy of the request and pick up any supporting documentation related to your accommodations.

On-line submissions are not secure. It is extremely unlikely this form would be intercepted, but if utmost confidentiality is a concern, please return to the forms page and use the PDF version which can be submitted in person, by mail, or by fax. See the Contact Us page for address and phone numbers.

Important! You should see an acknowledgment of your submission. Examine it carefully for errors. If you find any, or do not see an acknowledgment, contact the SDC at:
(530) 752-3184 (voice) or (530) 752-6833 (TTY).

Accommodations requested for:

Disability Specialist: 
Student Name: 
Student ID#:
Address:
City:
State:
Zip:
Phone:
E-Mail:

  Check here if this is a new address and/or phone number.

I acknowledge that by requesting academic accommodations, I am authorizing the SDC Disability Specialist to discuss information relevant to the recommended accommodations with faculty and staff who have a need to know. I understand that, as with all University activities, I am required to comply with the UC Davis Student Code of Conduct, including the responsibility to accurately represent my circumstances.

  A mark in this box signifies my acceptance of the above statement. I understand I will be asked to sign this form when I pick up my accommodations.

Exam Date:   Time:   Location:

Accommodation(s) Requested:

 

 
     

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Last updated December 6, 2007
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