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Disability Services Request & Identification Form

Disability Services Request & Identification Form

    Personal Information

    Legal Name:
     

    Preferred Name (if different):
     

    Date of Birth: (ex. MM/DD/YYYY)
     

     
     

    Student Identification Number:

    Current (Local) Address:
     

    Permanent Address (if different):
     

    Contact Info:
     

    Emergency Contact

    Emergency Contact Full Name:
     

     

    Student Information

    Major:
     

    If yes, which institution did you transfer from?
     

    Disability Information

    Please indicate your disability. Check all that apply.

     

    ADD/ADHDLearning DisabilityPsychological/PsychiatricChronic MedicalTraumatic/Acquired Brain InjuryBlind/Low VisionDeaf/Heard of HearingNeurologicalAutism Spectrum DisorderCommunication/Speech LanguagePhysical/Mobility impairmentAllergySubstance Abuse RecoveryTemporary Injury/ConditionOther

     

    If other, please describe:

    If known, at what age were you diagnosed?

    Please describe how you have experienced the following settings and any barriers you have faced:

     
     

    Documentation Information:

     

    Disability Services invites students who request reasonable accommodations to meet with the Coordinator of Disability Services to discuss their past use of accommodations and any disability-related barriers they anticipate or are experiencing at the School. While no external paperwork may be necessary to establish accommodations, medical records, psychoeducational testing and school records (such as an IEP or 504 Program) may help guide our conversation and provide information about specific requests. If this type of information is available, you can email the Coordinator of Disability Services, Crystal Wilson at cwilson@msmnyc.edu. Please do not delay meeting with Disability Services out of concern for not having appropriate paperwork.

     
     
     

    Accommodation History

    What types of accommodations have been helpful to you in the past?

     
     

    Accommodation Request

    Please list the nature of your current accommodation request:

    AcademicResidentialGeneral Campus AccessOther

     

    If other, please describe:

     

    If yes, please explain:

    Confidentiality Statement:
     

    Student’s Disability Services paper and electronic information is considered confidential pursuant to FERPA, and is kept secured. Information about disabilities and the use of accommodations is only used to arrange accommodations with other staff and faculty on a need to know basis, and is not recorded on any School record or transcript. In accordance with FERPA, disability related documents will not be released to persons who are not school officials without written consent of the student, unless a FERPA exemption applies. Students have the right to review the contents of their files with a Disability Services staff member.

     

    Reasonable accommodations will be determined and approved only after an interactive meeting and conversation shortly thereafter. Accommodations are based on student self-report and review of appropriate documentation.

     

    I affirm that I have completed this application truthfully and that I have read and understand the confidentiality statement and stated policies and procedures herein.

     
     
     


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