Office of Disability Services
Request for Services
Please complete this form and submit via email, fax, or mail to:
Charter Oak State College, Office of Disability Services, 55 Paul J. Manafort Drive, New Britain, CT 06053-2150
Email:  ODS@charteroak.edu	Fax: (860) 606-9673	Phone: (860) 515-3846

Student Information:
Full Name: _____________________________________________________________
Student ID#:________________
Telephone where we may reach you?  ____________________ 
May we leave a message or voicemail?  ___________
Charter Oak Email Address: _______________________________________________
Gender:  [   ] Male   [   ] Female
Nature of Disability:  Indicate any disability for which you are seeking accommodations.
[   ] Visual Impairment			[   ] Learning Disability			[   ] ADHD		
[   ] Psychiatric/Mood Disorder	[   ] Hearing Impairment		[   ] Physical/Medical
[   ] Other ______________________________________________________________

Learning Profile and History:
All information disclosed in this form is kept confidential and will not go into your academic file.  
Please describe any support services or devices you have used in previous academic or work settings:
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________________________
How does your disability, medical condition, treatment (including medications), impact your academic or work performance?

[  ] Reading			[  ] Math			[  ] Taking tests	
[  ] Study Skills			[  ] Organization		[  ] Retaining information
[   ] Writing			[  ] Meeting deadlines 	[  ] Communicating ideas
[  ] Maintaining focus		[  ] Prioritizing			[  ] Understanding instructions 
Do you use any of the following?
[   ] Screen reader		[   ] Screen magnifier 		[   ] Speech-to-Text Software
[   ] Tutor/Academic Coach	[   ] Closed captioning and/or transcripts			 
Is there any other information you would like to share about your disability that will support your request for accommodations?
______________________________________________________________________________
______________________________________________________________________________

Information About ODS Services

Please initial each line item to indicate that you have read and understand the information.

____ In order to receive academic accommodations, I am required to submit supporting documentation from a qualified evaluator stating my disability/medical condition, its impact on academic performance, and recommended accommodations.  More information about required documentation is provided in the checklist below.
____ I will provide the Office of Disability Services with a signed Release of Disability Information form, provided by the ODS.
____ There are no fees required for accessing reasonable accommodations.  In accordance with the Americans with Disabilities Act and Sections 504 and 508 of the Rehabilitation Act, I have the right to receive reasonable accommodations in order to have equal access to Charter Oak State College programs, course content and student programs.  
____ All documentation and personally identifiable information will be handled in a confidential manner.
___ I am required to provide each course instructor with a letter of accommodations, provided to me by the Office of Disability Services, for each term, session, or semester.
Required Forms and Documentation
[   ] Request for Services Form
[   ] Authorization to Release Disability Information Form
[   ] Supporting Documentation
Disability Documentation Guidelines:
1.	Provided by a qualified evaluator within the last five years.  Generally, documents older than five years will not be accepted.  
2.	Identify the disability.
3.	Describe how the disability impacts the individual’s academic performance and learning.
4.	Make recommendations for appropriate learning accommodations.  

Information contained within your file will be kept confidential and will not be shared with anyone outside Charter Oak State College without your prior written authorization.  Submitting the required documentation well in advance of the next term/semester will allow us sufficient time to put accommodations into place before the start of your courses.  Once documentation is received and approved, the Office of Disability Services will contact you to discuss accommodations and procedures.  
If you have any questions about how to access accommodations, please call the Office of Disability Services at (860) 515-3846 or email the office at ODS@charteroak.edu.  

For ODS Staff Use Only
Request  Approved / Unapproved
Basis for Decision: ___________________________________________________________
__________________________________________________________________________
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