DSO Application for Services

Student Information

Fitchburg State University offers reasonable accommodations to qualified students with documented disabilities. To request accommodations, complete this form and send copies of your disability documentation to the Disability Services Office (DSO) by mail, email or fax.

● Mailing address: Disability Services Office (DSO), Fitchburg State University, 160 Pearl Street, Fitchburg, MA 01420

● Email: disabilityserviceslist@fitchburgstate.edu

● Fax: 978-665-4786

Tip: Download the Rave Guardian App then add any medical information you want safety officials to know in case of an emergency.

Student ID

First Name

Last Name

Preferred Name

Pronouns

Date of Birth

Email

Please use your university issued email address

Personal Phone Number

Are you a Fitchburg student?

Intended Academic Major

What type of disability/disabilities are you requesting accommodations for?

Primary Disability

Other disabilities

Please check all that apply.

Diagnosis/Diagnoses

Please describe if you selected "other" above

Disability Impact

In your own words, please describe your disability and any symptoms which impact you in the academic and/or residence hall environment. Please include any accommodations used pre-college or at other institutions.

Symptoms of your disability that could interfere with your academic performance

Request for Disability Accommodations

Briefly describe any services that you require as a result of your disability. All requests must be supported by recent and relevant medical documentation substantiating the need for the requested accommodation(s). For detailed information about what disability accommodations are available at Fitchburg State, please visit www.fitchburgstate.edu/disability or contact the office directly at (978) 665-4020. Please note that reasonable accommodations will be determined after a comprehensive review of the student’s medical documentation and an interactive meeting between the student and the Director of Disability Services. All accommodations are highly individualized to a specific student’s need for equal access.

Testing Accommodations (describe):

Adaptive Technology and Software (describe):

Communication Devices (describe):

Course Materials in Alternative Format (describe):

Other (please specify):

Are you requesting a housing accommodation?

Are you requesting Meal Plan Accommodations?

Do you have a food/diet related disability

Executive Functioning Inventory

Do you find it difficult to estimate how long/how much time a task or assignment might take?

Do you find it challenging to create and maintain systems for organizing your schoolwork and materials?

Do you struggle to begin assignments or projects, feeling overwhelmed or unsure where to start?

Do you find it challenging to assess your own progress on tasks or assignments?

Do you struggle to decide which tasks or assignments to tackle first when faced with multiple deadlines?

Do you find it challenging to adapt to unexpected changes or disruptions in your schedule or routine?

Do you struggle with impulsivity, making decisions or taking actions without thinking them through?

Responsibilities and Consent

Student Responsibilities and Consent to be Registered

Student Digital Signature

Date

Documentation

For more information, please see our documentation guidelines.

Upload supporting document(s)