Lake Area Technical Institute

Occupational Therapy Assistant Program

FIELDWORK SPECIAL ACCOMMODATION REQUEST FORM

According to the guidelines of the Americans with Disability Act, it is the student’s choice and responsibility to reveal any information regarding a disability that may require special accommodation and thereby impact their educational experience.

Accommodations requested?

Summary of the accommodation agreed upon by the facility, LATI Fieldwork Coordinator, and student:

Signatures:

___________________________________________________________ _________________

Student Date

___________________________________________________________ _________________

Primary Fieldwork Educator Date

___________________________________________________________ _________________

LATI Fieldwork Coordinator Date