ACCESSIBILITY INTAKE FORM

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Student Information

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Please enter your 8-digit ID number (e.g. 01234567)

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Please provide the best number where we can reach you during the day.
Text Messages

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Please provide the email you check more often.

Disability Information

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Are there any academic adjustments (accommodations) you are requesting?

Academic adjustments may compensate for the disability when performing academic tasks.

Agreement

The Student AccessAbility Coordinator will review your request as soon as possible. The secretary will contact you to schedule an Intake Interview. Submissions of your request does not guarantee academic adjustments.

Agreement to initiate full process(Required) *
 

STATEMENT OF INFORMED CONSENT

I wish to apply for disability-related services at Norwalk Community College. I understand that services are determined on a case-by-case basis in accordance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 (as amended).

I understand that I should submit documentation of my disability to the Coordinator of Student AccessAbility Services. I understand that the documentation should be recent (preferably no more than three years old; one year for medical or psychiatric).  I understand that the documentation must be from a professional who is qualified to make the diagnosis (on letterhead, with signature), must specifically name the diagnosed disability, identify diagnostic testing mechanisms and procedures, and contain a narrative linking the testing results to the effect of the disability on learning and functioning in an educational environment, as well as to recommended academic adjustment(s).

I understand that academic adjustments need not change course requirements deemed essential by the college or fundamentally alter college programs.

I also understand that accommodations may be arranged in collaboration with faculty, administrators, and staff of NCC following my submission of an “Academic Adjustment Request” form every semester.  By submitting the “Academic Adjustment Request” form, I will be giving my explicit permission for the Coordinator (or designee), to furnish me with a “Letter of Academic Adjustment” and share with members of the administration, faculty, and staff of NCC, and appropriate outside Professionals information pertaining to me for support services (at the discretion of the Coordinator or designee).  Instructors are not required to provide academic adjustments without this official letter. I also understand that a minimum of one week’s prior notice is needed for carrying out of adjustments.

The first week of the semester (or the class subsequent to delivery), I agree to:

1.    confirm with the instructor(s) that (s)he received the “Letter of Academic Adjustment”

2.    to plan the carrying out of my academic adjustments

3.    to notify the Coordinator immediately if any further arrangements are required to implement my academic adjustment(s), or if I have any concerns. 

I understand that every effort will be made to protect the confidentiality of information I provide, however, if it is determined that I someone’s health or safety is at-risk confidentiality may be breached.

Please insert your initials below only if you have read and understand the process as described above, and you agree to fulfill your responsibilities and register with Student AccessAbility Services.  If you have additional questions before agreeing to register with Student AccessAbility Services insert the initials “QU.”

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Enter your initials to indicate your consent
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