Appendix D

SUPPORT SERVICES AGREEMENT (SSA)

College of the Redwoods

DSPS Support Services Agreement

Disabled Student Programs and Services

Date__________________ Semester_____________________

Name____________________________________ *SSN/ID#______________________

The above named student requires an academic accommodation to perform the tasks required for your class. This explanation is given with knowledge of the student and is to be considered as validation of the need for services based on assessment and review of disability verification documents by authorized DSP&S personnel. Please call our office at X4280, if you have any questions.

1. Notetaker (in class)_______________________________________________________________
   (Instructor should announce in class that a notetaker is needed, without identifying the person who needs the service. Direct any prospective notetaker to the DSPS office – only one notetaker per class is needed.)
2. Interpreter/Real Time Captioning___________________________________________________
3. Mobility Assistance_______________________________________________________________
4. Audio/Visual Equipment___________________________________________________________
   (Instructor may need to direct student where to sit, in front, near an electric outlet.)
   _______________________________________________________________________________
5. Alternate Media/Taped Text________________________________________________________
6. Temporary Medical Parking Permit__________________________________________________
7. Instructional Support_____________________________________________________________
8. Facilities/Special Equipment_______________________________________________________
   (Instructor may need to ensure student has the correct table/chair, etc.)
9. Test/Quiz Taking Facilitation in the ASC (special considerations)________________________
   _______________________________________________________________________________
   _______________________________________________________________________________
   Extended Time_____________ Breaks during test/quiz____________________
   Scribe/Transcription______________________
   Reader________________________________
   Module________________________________
   (By reservation only.)
10. Other (specify)___________________________________________________________________
    I, the undersigned, understand that the accommodations approved above are reasonable for certain classes or educational settings at this college and may not apply to other institutions.

STUDENT SIGNATURE__________________________________________

DSP&S STAFF SIGNATURE______________________________________

The services listed may be provided to a student by DSP&S only if all of the following conditions have been met: (1) the approved accommodations do not duplicate services or instruction which are otherwise available to all students; (2) the accommodations are directly related to the educational limitations of the verified disabilities of the student to be served; (3) the accommodations are directly related to the student’s participation in the educational process at this college; and, (4) the accommodations are intended to promote the maximum independence and integration of the student; and aid in supporting the student’s participation in educational activities consistent with the mission of the community colleges. In addition, the college may decline to provide accommodations that would necessitate fundamental alterations of academic requirements.

List of DSPS Services | How to Refer a student for Support Services | Tips for a Successful Student Interaction | Responsibilities | Acquired Brain Impairment | Communication Disabilities | Developmentally Delayed | Learning Disabilities | Physical Disabilities | Visual Impairments | Psychological Disabilities | Other Disabilities | Alternate Media | Appendix A Section 504/American Disability Act ( ADA) | Appendix B Assistive Computer Technology | Appendix C Procedure for Testing Accommodations | Appendix D Support Services Agreement (SSA) | Resources

Faculty Handbook Home | DSPS Home | CR Home