ADA CAS-AS Intake Form

ADA CAS-AS Intake Form

Thank you for contacting the Center for Academic Success-Accessibility Services (CAS-AS) at Hawai'i Pacific University. CAS-AS assists students with disabilities by helping to remove barriers to success and doing our best to level the playing field. If you'd like to discuss our services further, please complete the following intake form and follow the directions at the end. If you'd prefer, you may also complete this intake form via phone or in person during your first meeting with the ADA Accessibility Specialist. To schedule this appointment, please contact access@hpu.edu, via phone at 808-544-1197, or in person in Waterfront Plaza Building 6, FL. 4, Suite 440-B

CAS-AS reviews every student's request for services to determine what types of accommodations are reasonable and/or necessary for that student's success. Every student is considered as an individual through an interactive process. We strongly encourage you to complete this form and submit it as soon as possible because time is of the essence. The best time to request services is before classes begin.

Steps to receiving accommodations:
1) Complete Intake form (via submitting online, in person, or via phone).
2) Submit documentation from a medical professional that describes your disability, its effects on your academic performance, and the medical professional's recommendations (if any) for accommodations.
3) Schedule an appointment and meet with the Accessibility Specialist. Bring your medical documentation to the meeting.
4) After the meeting, the Accessibility Specialist will determine what accommodations (if any) are approved.
5) Instructors and other necessary staff will be informed in writing of the approved accommodations, and you will also receive copies of the accommodation notices.
6) You should stay in communication with course instructors and CAS-AS to ensure that your accommodation plan is being effectively implemented, and to make any necessary adjustments.
7) Before classes begin each following semester, you must submit the ADA Accommodation Renewal Request Form.

Have used accommodations with HPU? If Yes, please do not finish this form, copy the link below to fill out our renewal form instead.
https://forms.hpu.edu/view.php?id=346931
If NO, please continue to fill out this form.
Semester requesting accommodations for (EX: Fall 2022)
Name Name First Last
If you've had a name change, please provide all alternatives names.
Student ID #
Must be 9 characters. Currently Entered: 1 characters.
Hawaii Address Hawaii Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Permanent Address Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
HPU Email Address
Personal Email Address
Are you using military benefits with HPU?

Are you using military benefits with HPU? Yes, I am an active-duty military member Yes, I am retired from the military Yes, I am a spouse or dependent of a military member No
Student Status

Student Status 1st year (Freshman) 2nd year (Sophomore) 3rd year (Junior) 4th year (Senior) Grad Student Other Other
Major/Program
On which campus do you plan to take classes?

On which campus do you plan to take classes? On-campus (Main campus: Downtown or Hawaii Loa Campus) Online Satellite campus
Are you registered or will be registering for an 8-week course(s)?

Are you registered or will be registering for an 8-week course(s)? Yes No
Disability Information (please check all that apply)

Disability Information (please check all that apply) ADD/ADHD Allergy Asperger/Autism Brian Injury Deaf & Hard of Hearing Learning Disability Medical Conditions Mobility Impairment Post Traumatic Stress Disorder (PTSD) Psychological/Emotional Disability Speech & Language Impairment Temporary Visual Impairment Other Other
Please describe in your own words your disability/disabilities and how it affects your ability to function on a university campus.
Accommodations
What accommodations have you previously used?
Check what type of accommodations you are seeking?

Check what type of accommodations you are seeking? Academic/Classroom Accommodations Special Housing Accommodations (i.e. single rm, meal plan waiver) ESA Housing Accommodations Unsure
Please list the accommodations and services you are requesting.
If applicable, please list any adaptive technology you will be using.
How did you learn about our services?

How did you learn about our services? Website Physician Instructor Another Student High School/College Literature Parent Rehabilitation Agency Other Other