ADA Annual Report Form

Americans with Disabilities (ADA) Annual Report Form

Due by June 30 each year
Program Name*
5-digit Program ID*
This can be found on the Administration > Program Details page of DAISI
Person Completing Form:*

First NameLast Name
Fiscal Year*
For each category below, enter the totals for all adult education students served this past fiscal year.
Number of students disclosing any type of disability:*
Number of students referred for learning disability diagnosis:*
Number of students with diagnosed learning disability served:*
Number of students approved for HSE testing accommodations:*
Number of students approved for GED testing accommodations from GEDTS:*
Number of students approved for HiSET testing accommodations:*
Number of students who received instructional accommodations*
Provide the following contact information for your program's ADA Coordinator*

*If the ADA Coordinator at your program changes during the fiscal year, updated name and contact information must immediately be provided to your Adult Education Program Support Specialist.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Signature of Person Completing This Form*

Clear
Date Completed*

MonthDayYear
Date
Should be Empty:

Americans with Disabilities (ADA) Annual Report Form