Please note: this on-line submission form is not being sent via a secure server. If utmost confidentiality is a concern for you, please download the PDF version of the Accommodation Request Form which can be submitted in person, by mail, or by fax.

Please make sure you have completed all fields before submitting. You should see an acknowledgment of your submission. If you do not see an acknowledgment, contact the DLRC at: 312 499-4278 or TTY 312 499-4287, or email: dlrc@saic.edu.

* denotes required information

Accommodations requested for*
Student Name*
Address*
City*
State*
Zip*
Cell Phone*
Preferred Email Address*

Specify interpreters, captioners, assistive listening devices (ALDS) and/or other requests for each section/course as needed.

Course #1
Course Name and Number
Instructor
Instructor Email
 Accommodation(s) RequestedDays/TimesLocation
Lecture Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Discussion Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Lab/Studio Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Note Taker YES    NO
Course #2
Course Name and Number
Instructor
Instructor Email
 Accommodation(s) RequestedDays/TimesLocation
Lecture Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Discussion Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Lab/Studio Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Note Taker YES    NO
Course #3
Course Name and Number
Instructor
Instructor Email
 Accommodation(s) RequestedDays/TimesLocation
Lecture Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Discussion Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Lab/Studio Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Note Taker YES    NO
Course #4
Course Name and Number
Instructor
Instructor Email
 Accommodation(s) RequestedDays/TimesLocation
Lecture Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Discussion Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Lab/Studio Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Note Taker YES    NO
Course #5
5. Course Name and Number
Instructor
Instructor Email
 Accommodation(s) RequestedDays/TimesLocation
Lecture Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Discussion Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Lab/Studio Interpreters
Captioners
ALDS
Other (explain below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
what time(s):
 
Note Taker YES    NO

I acknowledge that I am responsible for notifying DLRC staff immediately of any changes to my schedule and/or services. I also acknowledge that by requesting accommodations, I am authorizing DLRC staff to discuss information relevant to the recommended accommodations with faculty and staff who have a need to know. I understand that, as with all SAIC activities, I am required to comply with the SAIC Student Code of Conduct, including the responsibility to accurately represent my circumstances.

A mark in this box signifies my acceptance of the above statement.*

After the form is submitted, your request will be processed and you will receive notification via email of the status of your request.