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Penn State Berks – Disability Services, 169 Franco Building, P.O. Box 7009, Reading PA 19610
610-396-6410 / Fax #: 610-396-6402

Responsibilities for Requesting and Providing Academic Adjustments, Auxiliary Aids and/or Services at Penn State University

This section is to be completed by the student requesting academic adjustments:

I am aware of the following:

[   ] student initials here

  • To receive the academic adjustments listed on my letter, I must request them from the instructor.
  • My instructor is not required to provide academic adjustments until I have presented and discussed my academic adjustments with him/her.
  • Requests for academic adjustments should be made as early in the semester as possible.
  • I must give a minimum of five working days to my instructor and/or D.S. for any testing adjustments requested. 
  • I must report changes to my schedule (drop, add, and/or withdrawal) to my disability specialist as soon as possible.

When requesting and obtaining academic adjustments, my responsibilities include the following:

[     ] student initials here

  • Schedule a private meeting with the instructor to present and discuss the academic adjustments listed in the letter.
  • Make arrangements related to the suggested academic adjustments with the instructor.
  • Leave the meeting with an understanding of the arrangements that were agreed upon.
  • Report problems or issues with academic adjustments to my disability specialist and instructor (i.e., the same day, the same week).  

By signing below, I acknowledge my Disability Specialist has reviewed the academic adjustments, the procedures for requesting academic adjustments, and the student rights and responsibilities for requesting academic adjustments with me.

Student’s Name (print): [student prints name] Date: [enter month, day, year]

Student’s Signature: [student signature]  PSU ID#:[enter PSU ID# ]

Disability Specialist’s Name: [enter Disability Specialist's Name]   Initials: [initial here]  Date: [enter month, day, year]

This section is to be completed by the instructor receiving the academic adjustment letter:

Note to instructors: Please return to Disability Services Coordinator Michelle Strawley, Franco 169, after form is complete. The academic adjustment letter on letterhead is your record of the student’s academic adjustments. If you would like a copy of this form please check the statement below. Otherwise, you can review a copy at any time by contacting Disability Services Coordinator at mns136@psu.edu or x6410.

On this date [enter month, day, year], the student named above presented the academic adjustment letter to me.

  • I understand my obligation to provide the identified academic adjustments.
  • If I have any questions or concerns, I will address these with the student first.
  • If further assistance is needed, I will contact Disability Services at mns136@psu.edu or 610-396-6410

For general information regarding how to work with students with disabilities, please refer to the ODS Faculty Handbook at: http://equity.psu.edu/ods/

Instructor’s Name (print): [print instructor's name]

Instructor’s Signature: [instructor's signature]

Course and Section: [course and section]

[  ] I would like a copy of this form sent back to me.

Revised 12/10/12

Please return the yellow form to Disability Services-Instructor should keep copy on letterhead.

Franco 169, 610-396-6410