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 strongly encourages students seeking services to provide documentation from a qualified healthcare professional that describes the disability and/or health condition, shares the functional impact on the student’s academic experiences, and includes recommended accommodations. Please see Documentation Guidelines on the Disability Services webpage, and be sure to bring documentation to your initial meeting with Disability Services, if not sent prior to the meeting.

 
 
 

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.