SPECIAL NEEDS REQUEST FORM Junior Lottery Spring 2019

 

If you feel you have a special need regarding your clerkship scheduling, please return this form to the Division of Clinical Education, Room 114K, 2900 Queen Lane , NO LATER THAN Noon on Monday, January 7, 2019. If your request is confidential please put the form in an envelope and mark it Confidential Special Request with your name on the outside of the envelope. All special needs requests will be reviewed by a Deans Committee.

 

If you have a special need and do not fill out a form, it is very unlikely that a change can be made. There is no guarantee of availability after the deadline. You must complete your lottery choices to be consistent with your request. If you do not complete the lottery process, a default randomized schedule will be prepared by the computerized system (it is a computer and does not know your needs).

 

Students requesting accommodations due to a disability at Drexel University need to present a current Accommodations Verification Letter (AVL) before accommodations can be made. AVLs are issued by Disability Resources (DR). For additional information, visit the DR website at drexel.edu/oed/disabilityResources/overview/, or contact DR for more information by phone at 215.895.1401, or by email at disability@drexel.edu.



Students who have a request related to a disability should only indicate that they are applying for accomodations on this form. DO NOT PROVIDE ANY DETAILS REGARDING YOUR REQUEST ON THIS FORM. Requests for accommodations must be submitted to Disablity Resources no later than 11/30/2017. Do not provide medical documentation or any information related to a disability directly to the Dean's Office or anywhere on this form. Requests related to a disability must be supported by an Accommodation Verification Letter (AVL) from the Drexel University Disability Resources and the student is responsible for submitting the AVL to the Senior Associate Dean of Student Affairs.

 

Not all requests can or will be granted. Requests are ranked based on need and may or may not be given any priority. You should submit your lottery choices consistent with your request and based on the assumption that your request will not be granted.

 

Students are responsible for providing their own housing.

 

DATE:

E-MAIL:

NAME:

PHONE #:

SIGNATURE:

 

PLEASE CHECK THE BOX(S) APPROPRIATE TO YOUR SCHEDULING SITUATION:

Reason for request?

 

Specific area needed?

Primary Caregiver of minor children

 

 

 

Philadelphia Area

 

 

 

Accommodation applied for via Drexel University no later than 11/30/2018 to Disability Resources - DO NOT SUBMIT ANY DOCUMENTATION to the Division of Clinical Education* -

 

 

Other Area (please specify)

 

 

 

(provide additional detail below if necessary - DO NOT PROVIDE ANY INFORMATION related to Office of Disability Resourses Requests on this form)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

rev. 10/09/2018
*Must be supported by an Accommodation Verification Letter from the Drexel University Office of Disability Resources. Requests for accommodations must be submitted to the Office of Disablity Resources no later than 11/30/2017. Do not provide medical documentation or any information related to a disability directly to the Dean's Office or anywhere on this form. Student is responsible for submitting Accomodation Verification Letter received from the Office of Disability Resources (AVL) to the Senior Associate Dean for Student Affairs as soon as it is available in order for it to be applied.