Disability Services for
Students
SELF-IDENTIFICATION AND REQUEST FOR ACCOMMODATIONS
For
STUDENTS WITH DISABILITIES AND OTHER SPECIAL NEEDS
Please complete the form on the reverse side to identify yourself
if you have a disability or a chronic illness which might warrant accommodations
while you are attending Southwestern Oregon Community College. The
College is firmly committed to providing reasonable accommodations
to those with properly documented special needs to ensure equal access
to all programs.
If you have a learning disability, a visual, hearing or mobility impairment,
a physical or mental illness or an invisible condition such as an eating
disorder or allergies, you are encouraged to complete this form. Whether
or not you are eligible for an accommodation, your completion of this
form will assist the College in responding to your needs.
If you are requesting accommodations under the Americans with Disabilities
Act (ADA) and/or section 504 of the Rehabilitation Act of 1973; you
must provide documentation of the existence of a disability which substantially
limits a major life activity. Please note the following criteria:
- Since the laws guiding eligibility for accommodations in grades
K-12 and post-secondary education differ, current documentation (within
1 to 3 years depending on the nature of the disability) including
recommendations which correspond with the demands of college will
help to support your transition. The documentation must provide evidence
of a substantial limitation to learning or another major life activity.
If documentation is not current or relevant, the College will require
an updated evaluation, the cost of which will be covered by the family.
- The evaluation must be conducted by a professional with training
and experience in the assessment of adolescents and adults. It must
be submitted on the evaluator’s letterhead.
- Documentation must include a description of the disability and
the results of comprehensive testing, including standardized, professionally
acknowledged measures for adolescent and adult assessment.
- Documentation must include recommended accommodations which the
College is being asked to consider providing. Each accommodation
recommended should include a rationale that correlates with specific
functional limitations which are supported by specific test results
and clinical observations. The information you provide will be kept
confidential except that which is relevant to faculty and staff who
are expected to provide accommodations, or if emergency treatment
might be required. If you are living in Student Housing and would
like the College to inform your Resident Assistant of your disability,
please note it on the form.
Date:____________
Last Name: _______________________ First Name: __________________
Middle Initial: ___
Home Telephone: ______________________________________________
Home Address: _________________________________________________________________
_________________________________________________________________
E-Mail Address: ________________________________________________________________
Describe your disability or chronic health condition.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Please list the accommodations you are requesting at Southwestern.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Identify any equipment or medication you currently use due to your
disability or condition.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Please add any additional information you wish to provide:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Please indicate (___Yes___No) if you may need an accommodation for
placement testing.
Please contact Tim Dailey, the ADA Coordinator,
at 541-888-7439 or tdailey@socc.edu if
you have questions about this form.
Return this form to Tim Dailey at Disability
Services for Students in Stensland 106 or email it to tdailey@socc.edu.
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