ࡱ> ;>:e bjbjqq 8$p\p\x y 8F$j'.)'+'+'+'+'+'+'$(+O'fNO'd'!!!F)'!)'!!r$T7%62F$'z'0'%2,@ ,7%7%&,]%!O'O'L ', > :  UTSA Student Disability Services (SDS) Accommodation Request Form Program Practicums, Internships and/or Field Placements Students with disabilities may be involved with internships, field work placements, practicums or student teaching as part of their academic program. Because these placements may require special consideration and coordination with community entities, SDS must be made aware of any particular accommodation requests for a particular placement on a case by case basis and engage in an interactive conversation with various academic departments as part of the coordination process. If a student requires an accommodation during their field placement, it is the students responsibility to request them far in advance. Because the student may not fully realize the need for accommodation and/or they may not have a sense of what the internship setting will specifically demand, SDS recommends that the student should initiate a meeting as early as possible prior to placement during which information about internship expectations might be shared so that once better informed, the student might be better prepared on what they need to initiate as part of their placement needs. Most importantly, the student must initiate early discussions with the academic unit and/or SDS in order to plan for accommodations since the nature and/or implementation of accommodations may vary across agencies. In addition, academic units may begin early agency involvement as part of the process for identifying needed accommodations with an external agency site. Name: Banner ID: Phone Number: Email: Todays Date: Semester/Year of Placement: Note: By submitting this form, you are giving SDS permission to disclose your status as a student with a disability/ies to appropriate University and placement officials. Academic Dept. Internship/Practicum/Field Placement Coordinator: ______________________________ Coordinator Email and/or Phone Number: ____________________________________________________ I am requesting the following accommodations for listed Practicum/Internship/Field Placement: DISCIPLINE/Course Number/section Coordinator: DISCIPLINE/Course Number/section Coordinator: Specific Accommodations Requested for this Practicum/Internship/Field Placement Site: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  Completed by SDS Staff: Received By: _____________ Counselor Verification: _____________ Date: ______     You may be entitled to know what information the University of Texas at San Antonio (UTSA) collects concerning you. You may review and have UTSA correct this information according to procedures set forth in UTS 139. The law is found in sections 552.021, 552.023 and 559.004 of the Texas Government Code. 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