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accessed or shared by authorized university officials with a legitimate educational interest. Documentation submitted to support an accommodation request, is reviewed by appropriate university personnel to determine eligibility and the reasonable accommodations needed to ensure equal access. Supporting documentation and any provided diagnosis remain confidential.) /Pg 11 0 R /K [16] >> endobj 93 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Student Rights) /Pg 11 0 R /K [17] >> endobj 94 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Students have the right to:) /Pg 11 0 R /K [18] >> endobj 95 0 obj << /Type /StructElem /S /P /P 31 0 R /E <20208020205265717565737420726561736F6E61626C65206163636F6D6D6F646174696F6E73> /Pg 11 0 R /K [19] >> endobj 96 0 obj << /Type /StructElem /S /P /P 31 0 R /E <2020802020506172746963697061746520696E20616E20696E646976696475616C697A656420696E7465726163746976652070726F63657373> /Pg 11 0 R /K [20] >> endobj 97 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202042652074726561746564207265737065637466756C6C7920616E6420776974686F7574206469736372696D696E6174696F6E> /Pg 11 0 R /K [21] >> endobj 98 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202048617665206469736162696C69747920696E666F726D6174696F6E206B65707420636F6E666964656E7469616C> /Pg 11 0 R /K [22] >> endobj 99 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202052656365697665207772697474656E206E6F74696669636174696F6E20726567617264696E67206163636F6D6D6F646174696F6E206465636973696F6E73> /Pg 11 0 R /K [23] >> endobj 100 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202041707065616C206163636F6D6D6F646174696F6E206465636973696F6E7320696E206163636F7264616E6365207769746820756E697665727369747920706F6C696379> /Pg 11 0 R /K [24] >> endobj 101 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Student Responsibilities) /Pg 11 0 R /K [25] >> endobj 102 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Students are responsible for:) /Pg 11 0 R /K [26] >> endobj 103 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202050726F766964696E6720616363757261746520696E666F726D6174696F6E> /Pg 11 0 R /K [27] >> endobj 104 0 obj << /Type /StructElem /S /P /P 31 0 R /E <202080202050617274696369706174696E6720696E2074686520696E7465726163746976652070726F63657373> /Pg 11 0 R /K [28] >> endobj 105 0 obj << /Type /StructElem /S /P /P 31 0 R /E <20208020205375626D697474696E672072657175657374656420646F63756D656E746174696F6E207768656E206E6565646564> /Pg 11 0 R /K [29] >> endobj 106 0 obj << /Type /StructElem /S /P /P 31 0 R /E <2020802020436F6D6D756E69636174696E672077697468204469736162696C697479205365727669636573206966206163636F6D6D6F646174696F6E206E65656473206368616E6765> /Pg 11 0 R /K [30] >> endobj 107 0 obj << /Type /StructElem /S /P /P 31 0 R /E <2020802020466F6C6C6F77696E6720756E69766572736974792070726F6365647572657320666F722072657175657374696E6720616E64207573696E67206163636F6D6D6F646174696F6E73> /Pg 11 0 R /K [31] >> endobj 108 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Student Acknowledgment) /Pg 11 0 R /K [32] >> endobj 109 0 obj << /Type /StructElem /S /P /P 31 0 R /E (I certify that the information provided is accurate to the best of my knowledge. I understand that submitting this request does not automatically guarantee approval of requested accommodations.) /Pg 11 0 R /K [33] >> endobj 110 0 obj << /Type /StructElem /S /P /P 31 0 R /E (Student Signature _____________________________________________ Date ______________________________) /Pg 11 0 R /K [34] >> endobj 111 0 obj << /Type /StructElem /S /P /P 31 0 R /E (PAGE 2) /Pg 11 0 R /K [35] >> endobj 112 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [233 0 R 0] /K [36] >> endobj 113 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [234 0 R 0] /K [37] >> endobj 114 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [235 0 R 0] /K [38] >> endobj 115 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [236 0 R 0] /K [39] >> endobj 116 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [237 0 R 0] /K [40] >> endobj 117 0 obj << /Type /StructElem /S /Figure /P 31 0 R /Pg 11 0 R /A [238 0 R 0] /K [41] >> endobj 118 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Provider Documentation Form) /Pg 12 0 R /K [0] >> endobj 119 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Student Name: ______________________________________________________________ Date of Birth: _______________________________________) /Pg 12 0 R /K [1] >> endobj 120 0 obj << /Type /StructElem /S /P /P 32 0 R /E (The student above has requested academic accommodations at either St. Lukes College or Morningside University. The Disability Services Office seeks information regarding the student's functional limitations.) /Pg 12 0 R /K [2] >> endobj 121 0 obj << /Type /StructElem /S /P /P 32 0 R /E (This form must be completed ONLY if the student does not have an IEP or 504 plan to submit to the Disability Services Office for review.) /Pg 12 0 R /K [3] >> endobj 122 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Provider Information) /Pg 12 0 R /K [4] >> endobj 123 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Provider Name: ____________________________________________________________) /Pg 12 0 R /K [5] >> endobj 124 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Credentials: ____________________________________________________________________________________________________________________________) /Pg 12 0 R /K [6] >> endobj 125 0 obj << /Type /StructElem /S /P /P 32 0 R /E (License Number: ___________________________________) /Pg 12 0 R /K [7] >> endobj 126 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Practice/Organization Name: ________________________________________________________________________________________________________) /Pg 12 0 R /K [8] >> endobj 127 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Office Phone: ____________________________________ Email: ___________________________________________________________________________) /Pg 12 0 R /K [9] >> endobj 128 0 obj << /Type /StructElem /S /P /P 32 0 R /E (Clinical Information) /Pg 12 0 R /K [10] >> endobj 129 0 obj << /Type /StructElem /S /P /P 32 0 R /E (1. What condition\(s\) or impairment\(s\) are you treating or evaluating that are the basis for the accommodation request?) /Pg 12 0 R /K [11] >> endobj 130 0 obj << /Type /StructElem /S /P /P 32 0 R /E (_________________________________________________________________________________________________________________________) /Pg 12 0 R /K [12] >> endobj 131 0 obj << /Type /StructElem /S /P /P 32 0 R /E (_________________________________________________________________________________________________________________________) /Pg 12 0 R /K [13] >> endobj 132 0 obj << /Type /StructElem /S /P /P 32 0 R /E (__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________) /Pg 12 0 R /K [14] >> endobj 133 0 obj << /Type /StructElem /S /P /P 32 0 R /E (2. What functional limitations affect this student in an academic setting?) /Pg 12 0 R /K [15] >> endobj 134 0 obj << /Type /StructElem /S /P /P 32 0 R /E (_________________________________________________________________________________________________________________________) /Pg 12 0 R /K [16] >> endobj 135 0 obj << /Type /StructElem /S /P /P 32 0 R /E (_________________________________________________________________________________________________________________________) /Pg 12 0 R /K [17] >> endobj 136 0 obj << /Type /StructElem /S /P /P 32 0 R /E (__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________) /Pg 12 0 R /K [18] >> endobj 137 0 obj << /Type /StructElem /S /P /P 32 0 R /E (3. Which major life activities are substantially limited?) /Pg 12 0 R /K [19] >> endobj 138 0 obj << /Type /StructElem /S /P /P 32 0 R /E /Pg 12 0 R /K [20] >> endobj 139 0 obj << /Type /StructElem /S /P /P 32 0 R /E /Pg 12 0 R /K [21] >> endobj 140 0 obj << /Type /StructElem /S /P /P 32 0 R /E (4. Are the limitations:) /Pg 12 0 R /K [22] >> endobj 141 0 obj << /Type /StructElem /S /P /P 32 0 R /E /Pg 12 0 R /K [23] >> endobj 142 0 obj << /Type /StructElem /S /P /P 32 0 R /E (PAGE 1) /Pg 12 0 R /K [24] >> endobj 143 0 obj << /Type /StructElem /S /Figure /P 32 0 R /Pg 12 0 R /A [239 0 R 0] /K [25] >> endobj 144 0 obj << /Type /StructElem /S /Figure /P 32 0 R /Pg 12 0 R /A [240 0 R 0] /K [26] >> endobj 145 0 obj << /Type /StructElem /S /Figure /P 32 0 R /Pg 12 0 R /A [241 0 R 0] /K [27] >> endobj 146 0 obj << /Type /StructElem /S /Figure /P 32 0 R /Pg 12 0 R /A [242 0 R 0] /K [28] >> endobj 147 0 obj << /Type /StructElem /S /P /P 33 0 R /E (Provider Certification) /Pg 13 0 R /K [0] >> endobj 148 0 obj << /Type /StructElem /S /P /P 33 0 R /E (I certify that I am an appropriately qualified professional familiar with this individual's condition and that the information provided reflects my professional opinion.) /Pg 13 0 R /K [1] >> endobj 149 0 obj << /Type /StructElem /S /P /P 33 0 R /E (Provider Signature ______________________________________________________________ Date ____________________________________________) /Pg 13 0 R /K [2] >> endobj 150 0 obj << /Type /StructElem /S /P /P 33 0 R /E (Please return this completed form to accommodations@morningside.edu) /Pg 13 0 R /K [3] >> endobj 151 0 obj << /Type /StructElem /S /P /P 33 0 R /E (Students must return this completed form, as well as the Initial Academic Accommodation Request Form in order for their request to be reviewed.) /Pg 13 0 R /K [4] >> endobj 152 0 obj << /Type /StructElem /S /P /P 33 0 R /E (5. If known, what accommodations or adjustments may help reduce the impact of these limitations in an academic setting?) /Pg 13 0 R /K [5] >> endobj 153 0 obj << /Type /StructElem /S /P /P 33 0 R /E (____________________________________________________________________________________________________________________________) /Pg 13 0 R /K [6] >> endobj 154 0 obj << /Type /StructElem /S /P /P 33 0 R /E (____________________________________________________________________________________________________________________________) /Pg 13 0 R /K [7] >> endobj 155 0 obj << /Type /StructElem /S /P /P 33 0 R /E (____________________________________________________________________________________________________________________________) /Pg 13 0 R /K [8] >> endobj 156 0 obj << /Type /StructElem /S /P /P 33 0 R /E (___________________________________________________________________________________________________________________________) /Pg 13 0 R /K [9] >> endobj 157 0 obj << /Type /StructElem /S 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