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Student Academic Modifications Request Form

Please indicate which of the following is related to this request. (Check all that apply) *
  • Chronic lung disease such as emphysema, chronic bronchitis, idiopathic pulmonary fibrosis, or cystic fibrosis
  • Moderate to severe asthma
  • Serious heart conditions such as heart failure, coronary artery disease, cardiomyopathy, or congenital heart disease
  • Immunocompromised conditions such as cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and immune weakening medications
  • Severe obesity (Body mass index of 30 kg/m2 or higher)
  • Diabetes, type 1 or 2 or gestational
  • Chronic kidney disease
  • Liver disease such as cirrhosis or chronic hepatitis
  • Hemoglobin disorders such as sickle cell disease and thalassemia
  • Neurologic conditions
  • Cerebrovascular disease
  • Cancer

Note: If you selected ongoing underlying medical condition(s), please securely provide either the COVID-19 Health Care Verification Form or documentation of the condition(s).  Documentation can be submitted to us via in person, fax to 512.245.3452, or upload to the Texas State File Transfer link.

Are you currently registered with the Office of Disability Services at Texas State University for the selected ongoing underlying medical condition(s)?
For which semester(s) are you requesting these additional modifications? (Check all that apply) *