Assistive Device Program
California State University, Fresno
May 6, 2003
Updated May 12, 2008
Policy No. G-5.5
Assistive Device / Auxiliary Assistance Application For Funding
1. Funds requested for which semester(s) and year:
2. Name:
3. Fresno State P/S I.D.#:
4. Job Title: Department:
5. Contact Phone #: Email:
6. Department Contact Name:
7. Department Contact Phone #: Email:
8. Status of Position:
- ☐ Staff
- ☐ Faculty
- ☐ MPP
If temporary position, please indicate period of employment:
9. Disability Condition(s): (Physician diagnosis must be attached)
10. Is disabling condition permanent? ☐ Yes ☐ No
11. Indicate which essential job function(s) is compromised by your condition. Attach a copy of your job description.
Assistive Device Program
California State University, Fresno
May 6, 2003
Updated 5-12-2008
Policy No. G-5.6
12. Auxiliary Assistance: Describe the specific functions for which assistance is being requested, e.g., reading, note taking, interpreting, and driving. Specify cost per hour, week, term and/or year per the following sample:
Fall 2003: Reader @ $8.50/hr for 5 hrs/week x 17 weeks
= 85 hrs x $8.50 = $722.50
Spring 2004: Reader @ $8.50/hr for 3 hrs/week x 17 weeks
= 51 hrs x $8.50 = $433.50
13. Equipment: Vendor and cost in as much detail as possible. Please list all components and prices separately including shipping costs, and attach a completed Requisition if possible. Include documentation on alternative vendor and cost.
| Auxiliary Assistance | Equipment | Total | |
|---|---|---|---|
| Fall | $ | $ | $ |
| Spring | $ | $ | $ |
| (if applicable) Summer | $ | $ | $ |
| Total | $ | $ | $ |
Amount of matching funds from your Department: $
Signature of applicant below indicates acceptance and agreement to conditions set forth in Assistive Device Program as outlined in Policy G-5.
Signature of Applicant Date
Signature of Department head if matching funds are available Date