You must be a current Prairie State College (PSC) student or have applied to PSC and been accepted with a Student Identification Number and PSC Email Address to complete this form. Please complete the Intake Form in its entirety. Inadequate information and incomplete Forms will delay the Intake Process.
Please note that completion of this form does not guarantee that you are eligible for services from the Office of Disability Services. All students must provide documentation of disability and complete the Intake Process to determine if they are eligible for reasonable accommodations in accordance with the U.S. Department of Education, Office of Civil Rights and Americans with Disabilities Act.
Enrollment Status 

Emergency Contact Information
Are you a client of the Illinois Department of Rehabilitation Services (DRS)? * 


Are you transferring to PSC from another college or university? 


Voluntary Self-Disclosure of Disability


How did you learn about Office of Disability Services (check all that apply)*: 
Confidentiality and Release of Information

The Office of Disability Services (ODS) is committed to ensuring that all information and communication pertaining to a student’s disability is maintained as confidential as required or permitted by law.

The following guidelines about the treatment of such information have been adopted by ODS and will be shared with students. These guidelines incorporate relevant state and federal regulations.
  1. No one will have immediate access to student files in the ODS except appropriate staff of ODS or Counseling and Academic Advising in which ODS is located. Any information regarding a disability is considered confidential and will be shared only with others within the College who have a legitimate educational interest.
  1. This information is protected by the Family Educational Rights and Privacy Act (FERPA).
  1. Sensitive information in ODS student files will not be released except in accordance with federal and state laws.
  1. A student’s file may be released pursuant to a court order or subpoena.
  1. If a student wishes to have information regarding their disability shared with others outside the institution, the student must provide written authorization to the Disability Coordinator to release the information. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released. The student should also understand that there may be occasions when, within the College, the Disability Coordinator will share information regarding a student’s disability at her discretion if circumstances necessitate such sharing and the Disability Coordinator has determined that there is an appropriate legitimate educational interest involved.
  1. A student has the right to review his/her own ODS file with reasonable notification.

I have been informed of this policy regarding confidentiality and the release of information from my ODS file. I understand that ODS may release information from my file to be used in a confidential manner with appropriate College faculty and officials who have a legitimate educational interest while I am a student at Prairie State College.

I also certify that the information on this Intake Form and the documentation presented is accurate and genuine.
Date: Tuesday, 7 February 2023 (EST)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
Signature

Informed Consent
By signing this form, I understand that….
• I am voluntarily self-disclosing that I have a disability

• I must submit appropriate documentation and complete the Intake Process before accommodations can be approved

• I must advocate for myself. College Faculty/Staff cannot speak with your parents due to FERPA (Family Educational Rights and Privacy Act of 1974) without your permission and a completed FERPA Form which authorizes a release of information on file with the Enrollment Services Office.


• I must complete the online Accommodation Request Form (www.prairiestate.edu/arf), each semester that I would like to utilize accommodations.

• If I make changes to my schedule or requesting changes to my existing accommodations I will need to complete a new Accommodation Request Form.

• Accommodations are processed on a first-come, first-served basis. Some accommodations may take up to 4 weeks to arrange.

• Accommodations are not retroactive. Approved accommodations will be effective from the date of the accommodation approval.

• Requests for accommodations must be made in a reasonable time frame, ideally when I register for the next semester. This will ensure that arrangements can be made to provide the accommodations or services. Early arrangements will enable PSC to provide comfortable and supportive classrooms from the first day of class.

• When my accommodation request is reviewed and processed, I will receive an email with the decision.

• My Professors will receive an Accommodation Letter, detailing approved accommodations via email by the Office of Disability Services.

• Additional documentation regarding my disability can be requested by the Office of Disability Services

• I will notify the Disability Coordinator, as soon as possible, if there is an issue with my approved accommodations. I will not wait until final grades are posted or until the course or activity is completed.
• Prairie State College is not required to lower or substantially modify essential requirements, make adjustments that would fundamentally alter the nature of a service, program, or activity or that would result in an undue financial/administrative burden or provide services of a personal nature, such as tutoring and typing.

• Prairie State College has a Grievance Procedure in place if a student is concerned that they have not received reasonable accommodations/services under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973.
Date: Tuesday, 7 February 2023 (EST)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
Signature