Request for Services Housing/Dining

Request for Services – Housing/Dining University of Northern Iowa Student Disability Services

The University of Northern Iowa, in compliance with the Americans with Disabilities Act (ADA), will provide window air-conditioners or single/special room assignments as a reasonable accommodation in select residence hall rooms of students with documented disabilities.

A residence hall is more than just a place to sleep and study. It is a place to relax, socialize, and partake in educational and recreational activities. Because this is a shared facility by hundreds of students participating in various residence hall activities throughout the day, living in a single room does not necessarily provide a student with a quiet, distraction-free environment.

Air conditioners may be installed in select residence halls for those with chronic health conditions. Typically, allergies are not considered disabling; however, all accommodations are determined on a case-by-case basis.

The dining services will have a registered dietician and/or staff member meet with students who require a special dietary modification based on a documented disability. Reasonable accommodations will include dietary instruction and/or special dietary meals being produced for the student.

Please note that administration of services will not occur until a completed Request for Services form and relevant documentation are on file at Student Disability Services (SDS).

PLEASE SEND THIS COMPLETED FORM AND DOCUMENTATION TO:

Student Disability Services 103 Student Health Center University of Northern Iowa Cedar Falls, IA 50614-0385

OR BY FAX TO:

319-273-7576

I. GENERAL INFORMATION Name: UNI Student ID Number: Gender: Date of Birth:

Current Mailing Address:

City: State: Zip Code:

Local Phone Number: Cell Phone Number:

Preferred E-mail Address:

If approved, when would this accommodation begin?

II. UNIVERSITY OF NORTHERN IOWA STATUS Current UNI Student: Freshman Sophomore Junior Senior Graduate Student Other (please explain):

Major:

Minor:

Prospective UNI Student: Not yet admitted to UNI (transfer/prospective incoming freshman/prospective graduate student) Prospective transfer student (admitted) Prospective incoming freshman student (admitted) Prospective graduate student (admitted) Other prospective student (please explain):

Anticipated Entrance Date: Semester (Spring, Fall, Summer): Year:

Anticipated Major:

III. RESIDENCE LIFE/DINING IMPLICATIONS Please describe in your own words your disability, including diagnosis as well as cause and date of onset, and how it affects you in general.

How does your disability affect your living in the residence halls and/or dining in the residential dining facilities?

What accommodation(s) are you requesting for your disability?

IV. STUDENT VERIFICATION I verify that the information contained within this document is accurate to the best of my knowledge. I understand that utilizing certain accommodations may require me to relocate to another residence hall and that my documentation may be shared with appropriate Department of Residence staff in order to develop an appropriate accommodation plan.

Student Signature: Date:

Chapter 22 Code of Iowa: This information is requested to determine your eligibility for accommodations. Only directory information may be released to third parties. All items are required and therefore incomplete forms may not be processed.