VISA (Verified Individual Services and Accommodations)
Student:      E-mail:      Phone:             

Staff:          E-mail:      Phone:             

The university is strongly committed to maintaining an environment that guarantees students with disabilities full access to its educational programs, activities and facilities. Current federal law (Americans with Disabilities Act, Section 504 of the Rehabilitation Act) and UW-System Board of Regents Policy 96-6, require us to make reasonable modifications in order to ensure there is no discrimination against qualified students with disabilities. The following accommodations are recommended for this student by the Student Accessibility Center (SAC). Services are effective through the expiration date listed. Revisions may occur pending additional information, changes in disability status, or periodic review. For questions/concerns regarding the provision of these accommodations contact the SAC staff member listed or the SAC main office at 229-6287.
This document and the information contained within MUST remain confidential

Instructional Accommodations and Services

Alternative Testing Services:
Adaptive Technology/Computer Use
Print Enlargment (Elec., CCTV, paper)
Braille Exam
Electronic Exam (audio, Braille, etc.)
Minimally Distracting Environment
Extended Time (1.5 X; 2X)
Library Assistance:
Adaptive Technology
Study Room

Other Services:

Mobility Assistance:
Accessible Chair/Table

Supplementary Services:
Assistive Listening Device
Sign Language Interpreter
Speech-to-Text Services
Captioned Audio-Visual Materials
Taped Lectures
Preferential Seating
Braille or Large Print Text and Materials
Electronic Text and Materials
Laboratory Assistance
Priority Registration

Course Modifications - This must be coordinated between student and instructor and in consultation with SAC staff if necessary:
Assignment Due Date Extension
Attendance Flexibility

I understand that provision of these services may involve SAC staff disclosing disability and/or medical record information provided by me with appropriate university personnel participating in the accommodation process.

Student Signature:      Date:                     
SAC Staff Signature:          Date:

Revised 07/07