Student Accommodation Request/Intake Form

Student Information

Please enter your information

First Name

Last Name

Middle Name

Coppin State University Student ID

Coppin State University Email

Please use your Coppin State University issued email address

Phone Number

Pronouns

If you have questions about the 'Pronouns' entry, you can refer to this online guide for using and understanding personal pronouns.

Date of Birth

I am a veteran:

Home Campus:

Specific Accommodation Information

What is your diagnosed disability?

Please describe your disability and how it affects your performance as a student.

What kinds of special equipment or auxiliary aids do you use on a regular basis?

Do you take medications that could impact your educational responsibilities?

Describe any serious illnesses or injuries you have had, not related to your disability

Agency Information:

Agency Information

Are you receiving assistance from any outside agency (i.e. Department for the Blind & Vision Impaired, Department of Rehabilitative Services) for academic, career, personal counseling or support?

Support Services and Academic Adjustments:

Support Services/Academic Adjustments

Check the services/academic adjustments that you have used before. You may check more than one.

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If "other", please describe:

Academic Tasks - Easy

Select the tasks that you can do easily.

Academic Tasks - Difficult

Select the tasks with which you have difficulty.

Educational Background

Please include school history/past schools. Have you received IEP support in the past?

What are your interests, talents, strengths, and/or hobbies?

Is English your first language?

Please list the disability related accommodations that you are requesting below.

UNIVERSITY of BALTIMORE SPECIFIC ACCOMMODATION INFORMATION

Please note—questions only appear here if you selected University of Baltimore as your home campus.

Documentation:

Upload supporting document(s)

Disability documentation must be:
• complete and up-to-date
• from a certified professional, medical physician, and/or psychiatric physician

Students will be given the opportunity to provide the appropriate document if documentation presented is insufficient. CCA may also, as appropriate, give assistance in locating a qualified practitioner to conduct an assessment.
For specific information about documentation guidelines, please visit our Registration Page.

Please review:

I have read the documentation requirements supplied by the Center for Counseling and Accessibility and I understand and agree to supply the requested documentation in order to verify my disability and receive services.

The information contained in this form is true and accurate to the best of my knowledge.