International Center University of Missouri Student Accommodation Request Form
The Accommodation Request Form is designed to communicate the type of accommodation a student with a 
disability will need when studying abroad. Together with the Coordinator for the Office of Disability Services, 
the student reviews the request form and determines the accommodations needed. The request form is then 
given to the appropriate study abroad staff member and sent to the overseas contact or program provider. The 
overseas contact or program provider reviews the accommodation needs and responds, identifying the 
accommodations that can be provided and how they will be implemented. The study abroad staff member then 
communicates this information to the student in writing and meets with the student as needed. 

Student’s name: 
Student ID No.: 
Phone:
E-mail: 
Study Abroad Program:
MU Study Abroad Contact: Paulina Perkins
Phone: 573/882-6007
E-mail: perkinspau@missouri.edu 
Fax: 573/882-3223
 

Instructions for U.S. Disability Services Specialist 

• Together with the student, please review the entire Accommodation Request Form. (There is no need, 
however, to complete pages that do not apply to the student’s disability). Please be sure to write 
clearly as this form will be faxed, as is, to the overseas site or program provider. 

• Place a check mark on the line that best describes the student’s accommodation needs. 
 
• Indicated whether the accommodation is “essential” (must have) or “preferred” (would like to have). 
Please be certain that “essential” is restricted to those services which the student must have to 
participate overseas.

• Provide further details on the line provided after each question. Sites vary greatly on the types of 
accommodations possible. Providing details and possible alternatives helps the overseas sites to arrive 
at creative solutions. 

• Forward the completed form to the appropriate study abroad staff member as listed above. 

• Even if the student does not require disability accommodation, please notify the appropriate study 
abroad staff member of the student’s disability. 


Instructions for Overseas Site or Program Provider 

Attached please find a list of accommodations requested for the above referenced student. A Disability 
Services Specialist has worked with this student to determine what accommodations are essential for his/her 
participation on this particular study abroad program. Please do the following: 

• Review the student’s accommodation needs. A list of definitions for terms used in this form is included 
at the end of the checklist. 

• Use the Response Form at the end of this document to comment on the accommodations you feel you 
can provide. Please attach additional pages if needed. 

• Suggest alternative means of accommodating the student whenever possible. 

• Fax or e-mail your response to the MU study abroad contact person listed above. 
 

BACKGROUND INFORMATION 

Since the type of disability which a student may have can vary greatly, the type of accommodations 
needed can also vary significantly. Below please find descriptions of various types of disabilities 
recognized in the United States. Students needs vary according to each individual. Therefore, it is 
important for the participating student to clarify the particular accommodations s/he may need. 

The term disability is definite in the United States as an impairment that significantly limits of restricts 
a major life activity such as hearing, seeing, speaking, breathing, performing manual tasks, walking, 
caring for oneself or learning. The following are the six types of disabilities addressed in this checklist: 

Chronic systemic conditions: Affect one or more of the systems of the body. This includes 
cancer, diabetes, epilepsy, HIV/AIDS. 

Hearing disabilities: Includes those who have difficulty hearing, have lost hearing 
in one ear or are completely deaf. 

Learning disabilities: Refers to significant difficulties in acquisition and use of 
listening, speaking, reading, writing, reasoning and/or 
mathematical abilities, with the presence of at least average 
intelligence. This includes such conditions as dyslexia, 
dyscalculia and dysgraphia, and can be extended to include 
attention deficit disorder. 

Mobility disabilities: Range from very limited stamina to paralysis of extremities. 
Conditions that may cause a mobility disability include 
arthritis, back disorders, cerebral palsy, spinal cord injuries 
and neuromuscular disorders. 

Psychiatric disabilities: Diagnosis of a mental illness from a licensed professional. 
This includes depression, bipolar disorder, anxiety disorders 
and schizophrenia. 

Vision disabilities: Include low vision, total blindness and partial site such as 
impaired field of vision. 

Disability Services Specialist to complete: 

Please briefly describe the nature of the student’s disability and how this disability may impact the 
student’s participation in student abroad programs (e.g., functional limitations): 




Mark either Essential or Preferred or Not Needed when indicated next to the accommodations and services below.
 

MOBILITY DISABILITIES 


Classroom  

Wheelchair accessibility: Essential Preferred Not needed Details:

Short distance between buildings: Essential Preferred Not needed Details:   

Lab and/or library assistant: Essential Preferred Not needed Details:  

Scribe: Essential Preferred Not needed Details:   

Grab bar/adjusted height toilet stool: Essential Preferred Not needed Details:  

 

Housing 

Wheelchair accessibility: Essential Preferred Not needed Details:  

Electricity adapter for motorized scooter: Essential Preferred Not needed Details:  

Short walking distance to classes and activities: Essential Preferred Not needed Details:  

Shower with bench: Essential Preferred Not needed Details:  

Grad bar/adjusted height toilet stool: Essential Preferred Not needed Details:  

Assistance in dining area for carrying trays, cutting food, etc.: Essential Preferred Not needed Details:  

Personal attendant services to assist with bathing, dressing, shopping and cooking (type and amt. of time): Essential Preferred Not needed Details:  

Housing for personal attendant: Essential Preferred Not needed Details:  

 

Transportation 			 

Wheelchair accessible (with lift): Essential Preferred Not needed Details:  

Short walking distance to transportation from classes, housing, activities: Essential Preferred Not needed Details:  

Personal attendant services to assist with transportation (type and ant.): Essential Preferred Not needed Details:  
 

Other (please specify) Essential Preferred Not needed Details:   


 

VISION DISABILITIES 

 
Classroom

Materials in Braill: Essential Preferred Not needed Details:  

Materials in large print: Essential Preferred Not needed Details:  

Materials in alternative formats: Essential Preferred Not needed Details:   

Service dog allowed in all areas: Essential Preferred Not needed Details:  

Taped textbooks: Essential Preferred Not needed Details:  

Reader: Essential Preferred Not needed Details:  

Scribe: Essential Preferred Not needed Details:  

Notetaking: Essential Preferred Not needed Details:  

Braille signage for buildings, elevators, classrooms: Essential Preferred Not needed Details:   

Guide (orientation/mobility assistance) on campus (indicate amount of time): Essential Preferred Not needed Details:  

Verbal description of visual information: Essential Preferred Not needed Details:  

 

Housing 

Guide – orientation/mobility assistance (indicate amount of time): Essential Preferred Not needed Details:  

Assistance reading menus, mail, etc.: Essential Preferred Not needed Details: 
 
Braille signage for public housing (e.g., dorms, apartment buildings, etc.: Essential Preferred Not needed Details:  

Other (please specify): Essential Preferred Not needed Details:  

 
 

HEARING DISABILITIES 

 

Classroom 

Notetaking: Essential Preferred Not needed Details:  

Sign language interpreters in one-on- one situations: Essential Preferred Not needed Details:   

Sign language interpreters in group settings: Essential Preferred Not needed Details:  

Language used (ASL, PSE, other – please specify): Essential Preferred Not needed Details:    

Induction loops or similar technology: Essential Preferred Not needed Details:  

Captioned videos: Essential Preferred Not needed Details:  

Real time translation/captioning: Essential Preferred Not needed Details:  

TTY (telephone for deaf users: Essential Preferred Not needed Details:  

Volume control for telephone: Essential Preferred Not needed Details:  
 

Housing

Visual alert system for telephone, door bell, fire alarm: Essential Preferred Not needed Details:  

Volume control for telephone: Essential Preferred Not needed Details:  

TTY (telephone for deaf users): Essential Preferred Not needed Details:  

Sign language interpreters in one-on-one situations: Essential Preferred Not needed Details:  

Sign language interpreters in group settings: Essential Preferred Not needed Details:  

Language used (ASL, PSE, other – please specify): Essential Preferred Not needed Details:  

Captioned television: Essential Preferred Not needed Details:   

Other (please specify): Essential Preferred Not needed Details:   

 

OTHER DISABILITIES (e.g., learning disabilities or chronic health conditions) 

 
Classroom

Reduced course load: Essential Preferred Not needed Details:  

Notetaking: Essential Preferred Not needed Details:  

Tape recorded lectures: Essential Preferred Not needed Details:  

Taped textbooks: Essential Preferred Not needed Details:  

Modified deadlines for assignments: Essential Preferred Not needed Details:   

Alternative ways of completing assignments (e.g., oral presentation instead of written paper): Essential Preferred Not needed Details:  

 

Test accommodations

Scribe: Essential Preferred Not needed Details:  

Extra time: Essential Preferred Not needed Details:  

Reader: Essential Preferred Not needed Details:  

Calculator: Essential Preferred Not needed Details:  

Special exam facilities (e.g., low distraction environment): Essential Preferred Not needed Details:   

 

Housing

Refrigeration for prescribed medication: Essential Preferred Not needed Details:  

Provisions to accommodate special dietary needs (specify): Essential Preferred Not needed Details:  

Other (please specify): Essential Preferred Not needed Details:  

 

GENERAL DISABILITY INFORMATION 

 

Campus-wide service

Personal counseling services: Essential Preferred Not needed Details:  

Academic support services (e.g., writing assistance, tutoring): Essential Preferred Not needed Details:  

Health services (specify type of service): Essential Preferred Not needed Details:  

Access to prescribed medication and medical staff to administer any necessary injections: Essential Preferred Not needed Details:  

 

Assistive technology

Scanner: Essential Preferred Not needed Details:  

Braille printer: Essential Preferred Not needed Details:  

Text magnification software: Essential Preferred Not needed Details:  

Large screen for reading magnified text: Essential Preferred Not needed Details:  

CCTV (magnifies hard copy print): Essential Preferred Not needed Details:  

Speech output software (specify software needed and language): Essential Preferred Not needed Details:  

Voice recognition system: Essential Preferred Not needed Details:  

Cassette tape recorder: Essential Preferred Not needed Details:   

Braille notetaking device: Essential Preferred Not needed Details:  

Adaptive keyboard and mouse: Essential Preferred Not needed Details:  

Computer operating system needed: Essential Preferred Not needed Details:  

Other(please specify): Essential Preferred Not needed Details:  

 

Library 

Private room to work with a reader: Essential Preferred Not needed Details:   

Text scanner: Essential Preferred Not needed Details:  

Braille display connected to computer: Essential Preferred Not needed Details:  

Computer with CCTV: Essential Preferred Not needed Details:  

Electronic access to library via modem: Essential Preferred Not needed Details:   

Assistance consulting catalogue: Essential Preferred Not needed Details:  

Assistance taking books off shelves: Essential Preferred Not needed Details:  

Assistance photocopying materials: Essential Preferred Not needed Details:  

 

SAFETY CONSIDERATIONS 

Please describe any safety and/or health considerations you anticipate for field trips and excursions: 


 

GENERAL COMMENTS 

Any additional comments or concerns about accommodations you may need (e.g., arrival concerns, 
financial resources, wheelchair repairs): 


 

CERTIFICATION BY DISABILITY SERVICES STAFF AND STUDENT 

 
DS Staff completing form: 
Phone:
E-mail:
Fax:

 

I certify that the accommodations checked as essential are reasonable accommodations that would 
generally be provided to this student at a U.S. institution. 

 

Signature of DS Staff:
Date:
 

I recognize that some of these accommodations may not be available at my study abroad sites, but 
that efforts will be made to provide alternative accommodations whenever possible. I give permission 
to the MU International Center study abroad staff to contact the overseas staff regarding my 
accommodation requests. If I do not request accommodations at this time, I understand that it is my 
responsibility to contact Disability Services and request accommodations if I should identify 
accommodation needs after I arrive at the overseas site. I understand that, at that time, Disability 
Services staff will contact the overseas site and attempt to facilitate reasonable accommodations. 

 

Signature of student:
Date: 

 

N52 Memorial Union Colombia, MO 65211 USA Phone +1 573 882 6007 Fax +1 573882
Web: international.missouri.edu
 

DEFINITIONS 

 

Accommodations Modifications or adjustments to a course, program, service 
or facility that enable a qualified student with a disability to 
have an equal opportunity to learn. 

 

Assistive technology Any piece of equipment that is used to increase, maintain or 
improve the functional abilities of a person with a disability. 

 

Captioned Audio portion of videotape is transcribed into writing at the 
bottom of the screen. 

 

Closed-captioned Audio portion of a videotape that can be displayed or hidden 
using special decoding equipment. 

 

Closed-circuit television (CCTV) Television that displays video from a camera in the same 
room, used as a form of document enlargement by 
magnifying and projecting text onto a screen. 

 

Induction loops Device installed in a room to transmit sounds to the student. 

 

Lab assistants Assist students (who have vision or mobility disabilities) with 
manual tasks in lab classes. 

Mobility orientation Assisting individuals with vision disabilities in becoming 
acquainted with new physical surroundings so that they can 
move about independently. 

 

Note takers Take notes for students whose disabilities prevent them from 
taking notes themselves. 

 

Personal aids Accommodations and aids that are personal in nature and 
that are generally the responsibility of the student, e.g., 
hearing aids, flashing light alarm clocks, etc. 

 

Reader Reads material that is not available in an alternative format 
(such as electronic, Braille or large print) for students who 
are vision impaired or learning disabled. 

 

Real-time transcription Consists of transcribing a lecture on-site and projecting it 
onto a screen in written language. 

 

Scanner Equipment that transforms print information into digital media 
so that it can be manipulated using a computer. 



Scribe Writes down what a visually impaired, mobility impaired or 
learning disabled student dictates. 

 

Service or guide dog Dog that has been specially trained to guide or perform tasks 
for a person with a disability, such as a person who is vision 
or mobility impaired. 

 

Sign language interpreters Interpret spoken language into visual language using hands, 
body movements and facial expressions for people who are 
deaf; may be needed in group settings (e.g., orientation 
sessions) or one-on-one settings (e.g., doctor’s 
appointment). 

 

Speech output software Computer software that allows computer text to be read out 
loud for individuals unable to read computer print onscreen. 

 

Test accommodations Modified administration of a test (e.g., extra time, having test 
read to student, allowing student to dictates his/her answers 
to a scribe or tape recorder). 

 

TTY (Text telephone) or TDD Small typewriter device used by hearing impaired or deaf 

(Telecommunications Device individuals to have telephone conversations with hearing 

for the Deaf) individuals. 

 

Voice recognition system Computer types onto the screen what is verbally spoken. 

 

Wheelchair accessible Physical space arranged so that a person using a wheelchair 
is able to use the facilities independently (e.g., elevators or 
ramps where there are stairs, curbs or even surfaces and 
doorways into rooms or toilets that are at least 82 cm wide 
with door open 90 degrees); accessibility should be 
assessed in libraries, health facilities, classroom buildings, 
sports facilities, dining halls, computer lab buildings, 
residence halls, streets, transportation, etc. 

 


ACCOMMODATION RESPONSE FORM (for completion by overseas site or program provider) 

 
Below, please address the following issues as they pertain to (name of student): 

 

Please state the individual who is the key contact for disability-related issues at your institution and 
provide contact information. 

 

Key contact: 

Address:

Phone: 

E-mail: 

Fax: 

 

Please list the individuals at your institution have been, or will be, informed of this student’s disability. 
Please be sure to include each individual’s name, title and relationship to the student. 

 

Name Title Relationship to student:

 

After reviewing the student’s accommodation needs, please describe what accommodations your 
institution will provide for this student in the following areas: 

 

Classroom:

 

Housing:

 

Transportation:

 

Campus-wide service:



Assistive technology:
 

Library:

 

Safety considerations:
 

General comments:

 
Signature of overseas contact or provider: 
Date:         

 

Thank you for taking the time to respond to this student’s accommodation needs. Please fax or e-mail 
your response to the MU International Center study abroad contact listed on page one. 


N52 Memorial Union Colombia, MO 65211 USA Phone +1 573 882 6007 Fax +1 573882
Web: international.missouri.ed