Accessible Furniture / In-Class Equipment Request Form - Services To Students With Disabilities
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1ACCESSIBLE FURNITURE / IN-CLASS EQUIPMENT REQUEST FORM
Services to Students with Disabilities
CALIFORNIA STATE UNIVERSITY, FRESNO
_________________________________
Student Name:
Request for: Fall
Winter Spring Summer 20____
_______________________
Student ID#:
CSUF Email: ____________________________ @mail.fresnostate.edu
Contact Phone: ________________________________
(circle one)
home
work
cell
It is MY responsibility for all modifications and new requests, to meet with my Disability Management Specialist
(DMS) at least ten (10) working days prior to the start of the semester to review and approve the request.
It is MY responsibility to submit my request to the SSD office in a timely manner to allow at least ten (10) working
days to process and fulfill my request.
It is MY responsibility to inform SSD immediately should there be any change in my class schedule, classroom
location, cancellation of service, or any questions or concerns.
It is MY responsibility to notify SSD immediately if furniture or equipment is missing or damaged during the time it is
assigned to me, so it can be replaced.
I have read and agree to the above responsibilities and statements:
Student Signature __________________________________________________________ Date __________________
FURNITURE / IN-CLASS EQUIPMENT REQUESTED
_____ Table _____ Chair _____ Other: _______________________________________________________________
CLASS SCHEDULE
List only those courses for which you are requesting Accessible Furniture.
(Example:,
75624,
COUN 206-01,
Smith,
8-9:10,
ED171)
Class #
Class/Section
Instructor
Day/Time
Location
Class #
Class/Section
Instructor
Day/Time
Location
Class #
Class/Section
Instructor
Day/Time
Location
Class #
Class/Section
Instructor
Day/Time
Location
Class #
Class/Section
Instructor
Day/Time
Location
Request approved per DMS/SSD Staff: ________________________________________ Date: ___________
White – SSD Canary – Student
Received:
Z:\SSD forms\ACCESSIBLE FURNITURE REQUEST FORM - Copy.docx
Last Updated: 12/21/2010
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