CMU Off-Campus Programs - Student Disability Form

Student with Disability Information Card

If you have a documented disability, the following information is requested in order to facilitate your full participation in university programs. Please complete this form and click "Submit". If you have any questions, please contact the ADA Liaison for CMU Off-Campus Programs at (800) 950-1144, ext. 3264. Any disability information you provide remains confidential.

Name:
Student ID#:
Address:

City:
State: Zip:
Phone: ( ) -
Email:
Program Center:
Please check any disabilities that apply:

ADHA	Hearing Impairment
Learning Disability	Orthopedic Impairment
Traumatic Head Injury	Vision Impairment
Other Chronic Condition

Requested accomodation; please check any that apply:

Alternative Reading Format	Sign Language Interpreter
Extended Test Time (time and a half)	Readers for Test
Note Taker	Special Seating
Other

other services...

Graduate Advising

Undergraduate Advising

Transfer Credit

Transfer Guides

Prior Learning Credit

Order Textbooks

Disability Services

Off-Campus Library