WCSU Accommodation Intake Form

Introduction

Students interested in registering with AccessAbility Services (AAS) for the first time to request accommodations should complete this form and submit any supporting medical documentation regarding their disability. If you have previously requested accommodations through this form, and want to view your request and associated materials, you should log into WCSU Accommodate Portal.

Accommodation Process:

After filling out this form, you will receive an email instructing you to schedule an intake meeting to discuss your request. AAS engages in an interactive process with each student and reviews requests for accommodations on an individualized, case-by-case basis. Appropriate academic services and accommodations are provided based on a student's functional limitations in the academic setting. When scheduling an intake meeting, please indicate if you will require any accommodations for the meeting; such as, captioning, interpreting, large print, and/or information about accessible parking.

Student Information

First Name

Last Name

Middle Name

WCSU ID

WCSU Email

Your WCSU email address is the official form of communication for WCSU.

Personal Email

Cell Phone #

Gender Pronouns

Are you a transfer student?

Are you a commuter student?

Are you a University Athlete?

Are you a Military Veteran?

Are you an EAP student?

Are you an Honor's Student?

Are you part of Greek Life?

Emergency Contact Name?

Emergency Contact Number?

Emergency Contact Relationship?

Accommodation Information

What is your documented disability?

What accommodations are you requesting?

Did you receive any academic assistance in high school?

Please describe the impact of your disability or impairment and how it affects you in school and/or outside the classroom

What medication or treatments are you currently receiving? (include medication dosage if known)

Please share any other information that you feel would be helpful to AAS

Are you a client of the Bureau of Rehabilitation Services (BRS)?

Are you receiving services from an area community resource (e.g., DMHAS, DCF, etc.)?

Are you receiving services from other professionals in the community (e.g., therapy, counseling, tutoring, etc.)?

Are you receiving services or have you received services from an on-campus service (e.g., Counseling Center, CHOICES, Tutoring Resource Center, etc.)?

Evidence of Disability

While you are a vital source of information, AAS may request information from other sources in order to establish a disability and the impact it has on living and/or learning in a postsecondary environment. Documentation may include: assessments; reports; letters from qualified evaluators, professionals or institutions; high school documentation (IEP, 504 Plan, Summary of Performance), etc. If you have documentation regarding your disability, please upload it now. If not, you will be able to upload your documentation later. If you have questions about what type of documentation may be needed, please visit AccessAbility Services Documentation Guidelines webpage. Students who need assistance scanning and uploading documents may visit AccessAbility Services located in White Hall 005.

Upload supporting disability documentation

Release Authorizations

The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, is a federal law designed to protect the privacy of and limit access to the educational records of students. No one outside of Western Connecticut State University (WCSU) shall have access to nor will the University disclose any information from a student’s educational records without the permission of the student unless such actions are covered by certain exceptions as stipulated in FERPA. Consent from the student is requested in advance with whom the student’s confidential information and records may be released/shared, or from whom confidential information or records may be obtained. Confidentiality is not maintained in cases of child abuse, or suicidal/homicidal intent.

AccessAbility Services (AAS) works to preserve confidentiality of student information as required by applicable federal and state laws and regulations. For the purposes of FERPA, the university considers all students to be independent. Therefore, information will not be shared with family members/parents and/or treating providers without consent. Additional information regarding confidentiality and maintenance of records is available below. Visit WCSU FERPA information for additional information.

I understand that consents granted via use of this form remain in effect until rescinded via written, signed and dated notification (which may be done via email) to AAS.

I make the following authorizations to release information pertaining to my academic, medical and/or personal information for the purpose of assisting me at WCSU, as well as in determining reasonable and appropriate accommodations. I acknowledge and authorize that my digital signature, shall be as valid as the original.

Parents, guardians and/or designated family member(s).

Allowed name(s)

Explain any exceptions to parent, guardian and/or designated family member here:

Treating physician, psychiatrist, therapist, counselor, etc.

Explain any exceptions to treating physician, psychiatrist, therapist, counselor, etc.:

Authorization

Type Name to Digitally Sign

Release Authorization Date

Confidentiality and Maintenance of Records

AccessAbility Services will maintain the confidentiality of all student records as required or permitted by law.

Student records are protected by the Family Educational Rights and Privacy Act of 1974 (FERPA). FERPA is a federal law that affords students certain rights regarding their education records. The University considers all students to be “independent” as it relates to FERPA.

Please note the following:

AccessAbility Services (AAS) is the University agent charged with the responsibility for collecting and maintaining documentation related to students’ conditions.
The documentation provided to AAS is confidential and only shared with others with the expressed written permission of the student, except in the case of a compelling reason, such as a threat to an individual’s safety and/or an emergency situation or when their is internal educational need to know.
Consent of the student will be requested prior to releasing documentation to a third party. Confidentiality is not maintained in the case of child abuse, suicidal or homicidal intent.
All documents submitted to AAS are maintained in a confidential electronic case management system, including information about student demographics, academic programs, documentation of the condition(s), accommodations, and student contacts with AAS.
AAS' electronic case management system is hosted on a secure server and is developed and maintained using industry best practices. AAS' electronic system does not share information with other databases throughout the University (e.g., Banner, etc.).
Any documents provided to AAS in paper form are scanned, uploaded to the electronic case management system, and then shredded immediately.
Access to the electronic case management system is limited to authorized AAS personnel.
Once a student no longer has contact with AAS (e.g., graduates, leaves the University, etc.), student files are securely stored and destroyed in accordance with the State of Connecticut’s Records Retention and Disposition Schedule.

I understand the confidentiality and maintenance of records statement

Confidentiality Notice Date