Forms

The following is a list of commonly used forms by the Disability Resource Center.  In order to print these documents, links to Word and PDF versions are provided for you.

 

Alternative Exam Request Form

Alternative Exam Request Form

Disability Resource Center

The Disability Resource Center will provide alternative exam arrangements for students whose disabilities necessitate this accommodation, and whose professors are unable to accommodate them due to restrictions of time and space.  It is the student’s responsibility to get this form filled out and returned to our office at least three days before the date of the exam.  Unless arrangements are made with the instructor, the student will take the exam at the scheduled class time. 

TO BE FILLED OUT BY THE STUDENT

Student’s Name                                                                                   Phone #                       ______

Instructor’s Name                                                                               Phone #                                  

Instructor’s Office Location                                                                Course                         _____________

Date of Exam                                                              ____________Time of Exam                         ______

Accommodations Needed – Check All That Apply to You

Extended Time ________                  Distraction-Reduced Environment__________                    

Computer__________                       Large Print (font size)__________

Reader __________                          Scribe (writer)__________

Other __________________________________________________________________                                                                                                       

Student’s Signature ________________________________           Date ________________         

TO BE FILLED OUT BY THE INSTRUCTOR

(Instructions: Check one for uncompleted exam and one for completed exam)

Uncompleted Exam Will Be:

             Delivered by the instructor to the DRC office (Webster Hall 100)

             Sent by e-mail (tizonm@mail.montclair.edu)

             Sent by FAX (655-5308)

             Delivered by Student in sealed, signed envelope

Completed Exam Will Be:

             Delivered by the DRC to the department mailbox ____________________

______ Delivered by the DRC to instructor’s office (Location) __________________

______  Picked up by the instructor at the DRC (Date & Time)                                          

______ Scan and email copy to the instructor’s email_____________________________

______ Delivered by Student in sealed, signed envelope

 

Special Testing Instructions (ie., open book/notes, use of calculator, etc.)                                       

                                                                                                                                               ______

 

Instructor’s Signature ____________________________       Date _________________

If you have any questions or concerns, please contact the DRC at (973) 655-5431. 

 

Alternative Text Request Form

 

Alternative Text Request Form

Disability Resource Center

 

Name:__________________CWID#: ______________________Phone_____________________

 

Course Number & Title:_____________________Instructor:______________________________

 

Title of Text:____________________________________________________________________

 

Author:_________________________________Publisher:_________________________________

 

ISBN#:_________________Copyright year:_________   Edition: _________  Chapters/Pages:_______

 

Semester:  _____ Fall _____ Winter      _____ Spring        _____ Summer           Year: ______                              

 

Format Preferred:     Electronic/Text           Audio                    Software Preferred:            MS Word             PDF

 

In consideration of the provision of textbooks and course materials in alternative text formats, Student acknowledges and agrees to the following:

  • I understand that I must document a qualifying disability.
  • I understand that I must own a physical copy of all materials requested in alternative format.
  • I understand that I must be currently registered and enrolled in the particular class or classes for which I am requesting alternatively formatted materials.
  • I agree not to copy or reproduce alternatively formatted materials, nor allow anyone else to do so.
  • I understand that I assume all risk for damage to or loss of materials while they are signed out to me.
  • I agree to return all materials to the Disability Resource Center promptly upon completion of the semester.
  • I understand that failure to adhere to these regulations may be considered a violation of federal and/or state laws and may result in civil or criminal prosecution, payment of fines or other monies to the copyright holder, and/or incarceration.

 

Before receipt of materials, this agreement shall be signed by the student and the designated university official and kept on file.

 

I have read and understand the policies and procedures outlined above and agree to comply with them.

 

________________________________________________________________________

Student                                                       CWID                                                  Date

 

________________________________________________________________________

DRC Representative                                                                                               Date

 

Office Use Only:

          Course Syllabus Attached                       Proof of Purchase (date, location, & amount paid)

 

 

Confidentiality and Release of Information

 

Confidentiality and Release of Information

Disability Resource Center

The Disability Resource Center is committed to ensuring that all information regarding an individual is maintained as confidential as permitted by law.  Any information that is collected by the office is used for the benefit of the individual.  This information may include test data, grades, biographical history, disability information, and case notes.

No one except DRC staff has automatic access to files.  Disability-related information is to be treated as confidential information and shall be shared with others within the institution on a need-to-know basis only.  For example, University faculty and staff do not have a right or a need to access diagnostic or other information regarding an individual’s disability.  They only need to know what accommodations are necessary and appropriate to meet the individual’s disability-related needs, and then only with permission of the individual.

Information in files will not be released except in accordance with federal law, which requires release in the event that an individual states he/she intends to harm him/herself or another person(s).  Confidentiality is not maintained in the case of child abuse, suicidal or homicidal intent.

I understand that if I request the DRC to facilitate accommodations on my behalf, they may need to consult with other University personnel.  Circumstances that may warrant such disclosure include: requests for accommodations or services; concerns for the student’s health; special circumstances in housing; special financial aid considerations; or grievance procedures. 

I give my permission to have disability-related information shared with the following appropriate University personnel to facilitate such requests: (Please check and initial to give consent)

        Instructors                        

        Residence Education & Services              

        Financial Aid                    

        Registrar’s Office                                                

        Academic Advisement                            

        CADA                                                                 

        CAPS                                                                   

        Health Center                               

        Parking & Transportation Services                       

        Dean of Students                                                  

        Parent(s) or Guardian(s)                                       

        Physician                          

        Other:                                                      

I furthermore release all parties stated here within from any legal liability resulting from the release of this information, understanding that all parties involved will exercise sufficient safeguards while using this information.

Name (print): _________________________________       CWID#:____________________

Signature: ___________________________________         Date:_______________________    

 

 

Consent for Release of Information to Disability Resource Center

 

Consent for Release of Information to

Disability Resource Center

 

I, ________________________________________,

give my permission for

_______________________________________ to

release information pertaining to my disability.  I understand

that documentation of disability is necessary in order to

determine eligibility to receive accommodations of

Montclair State University.

 

 

Student Name: ____________________________ CWID: ______________________

Address (street): _______________________________________________________

(city) __________________________________(state) _______ (zip) ______________

Phone Number: ________________________________________________________

Physician’s Name: ______________________________________________________

Address (street): ______________________________________________________

(city) __________________________________(state) _______ (zip) ______________

Phone Number: _________________________________________________________

 

 

Grievance Procedure

 

Grievance Procedure

Disability Resource Center

  • Montclair State University is committed to the ideal that all students should have recourse from unfair and improper action on the part of any member of the university community.  If, at any time, a student feels that he or she has been subject to unjust actions or denied his or her rights, redress can be sought through the filing of a grievance, or an appeal of the decision/action taken in response to a grievance, within the framework of policy and procedures.
  • Montclair State University has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act or the Americans with Disabilities Act of 1990.
  • Students who have a complaint regarding a disability issue, or who feel they have been the subject of possible discriminatory treatment on the basis of their disability, should direct their initial complaint by meeting with the Director of the Disability Resource Center or by completing this form.  Grievances should be filed within 20 days of the time the claimant becomes aware of the alleged violation.
  • Upon receipt of said complaint, the Director will investigate the complaint by contacting all interested parties.  A resolution will be offered to the student within 10 working days.
  • If the student’s complaint is against the Disability Resource Center office or staff, he/she should meet with or send this completed form to the Dean of Students, who will follow the above procedure.
  • If the resolution is not satisfactory, the student should make an appointment to pursue the grievance with the University’s Section 504 Compliance Officer, Dr. Shannon Gary.
  • Although students are encouraged to attempt to resolve all grievances using the internal grievance procedure, the student has the right to file an external grievance with the Office of Civil Rights.  Complaint forms are available in the Disability Resource Center.

To file a complaint regarding accommodations or services, please provide the following information:

Name ______________________________________________________                                                                                                                     

CWID #: ___________________________________________________                                                                                             

Home Address: ______________________________________________                                                                                  

___________________________________________________________

City                                          State                            Zip Code

Phone Number(s):____________________________________________

Email Address: ______________________________________________     

Counselor (DRC): ____________________________________________

Please address the following

1. What is the nature of your concern/complaint?

__________________________________________________________

2. What steps have been taken to resolve the concern(s)?

__________________________________________________________

3. What action would you like to see taken to resolve this issue?

__________________________________________________________

4. Other comments:

__________________________________________________________

 

 

Housing Accommodation Request Form

 

REQUEST FOR HOUSING ACCOMMODATIONS

The Office of Residence Life and the Disability Resource Center work together to accommodate students with disabilities or medical needs in the residence hall setting.  Medical accommodations may be requested by students with physical or psychiatric disabilities and will be reviewed on a case by case basis.   A review of your request and the submitted medical documentation will be used to determine if your request is both reasonable and appropriate under the law.

This process is for students who have disabilities.   Federal law defines a disability as “a mental or physical impairment that substantially limits one of more major life activities.”  The presence of a disability and/or medical condition does not guarantee that your request will be approved.  The degree of impairment or functional limitation must be significant enough to make the accommodation necessary.

Accommodations can only be granted if appropriate space is available.  Assignment to a specific residence hall and roommate preference cannot be guaranteed.   Learning disabilities or attention deficit disorders do not warrant special housing accommodations.

In order to request housing accommodations, you must:

ü  Pay your housing application fee on time.  If your payment is late, your accommodation request will be considered, but cannot be guaranteed.

ü  Complete Forms 1 and 2.  (attached)

ü  Have your medical provider complete Form 3.  (attached)

 

  • Note that medical documentation from family members will not be accepted.
  • All requests must be submitted to the Disability Resource Center by March 15th for fall placement for returning students. Spring requests must be submitted by December 15th.
  • All requests from incoming freshmen and transfer students must be submitted by May 11th.
  • All completed forms must be submitted to the Disability Resource Center, Webster Hall 100.        Forms may be faxed to 973-655-5308 or emailed to drc@mail.montclair.edu.

 

REQUEST FOR HOUSING ACCOMMODATIONS

Form 1 – To Be Completed by Student

Student Name______________________________    MSU ID#_____________________________

Permanent Address________________________________________________________________

Cell Phone number________________________________________________________________

Email address____________________________________________________________________

I am requesting housing accommodations for (semester) __________________________________

Please specify the medical or psychological disability for which you are seeking accommodation.

_______________________________________________________________________________

Please specify what accommodations you are requesting.

_______________________________________________________________________________

Are you currently being treated by a physician or other medical professional for this   disability?_______________________________________________________________________

What is your medical professional’s name, address, and phone number? _______________________________________________________________________________

Please provide a thorough explanation of how the request relates to the need.  Describe how this accommodation will reduce the impact of your disability ________________________________________________________________________

 

REQUEST FOR HOUSING ACCOMMODATIONS

Form 2 – To Be Completed by Student

Release of Information and Statement of Understanding

I have read and understand the Montclair State University procedures for requesting housing accommodations, and I agree to the terms and conditions.

I understand that incomplete forms will not be considered.  A completed request consists of:

  • Form 1 to be completed by student
  • Form 2  to be completed by student
  • A completed and signed Form 3 submitted by my medical practitioner

Forms should be submitted to The Disability Resource Center

Webster Hall 100

Fax number – 973-655-5308

Email – drc@mail.montclair.edu

I understand that this request is for a housing accommodation that meets my documented needs.  Building, room type, and roommate requests are not guaranteed.

I understand that that my personal medical information will be shared on a “need to know” basis with other university offices.

By my signature below, I give my consent to the Disability Resource Center to contact my physician if additional information is needed.  Any such discussion will focus on the disability disclosed on this form only.  

Denied requests may be appealed through the University’s internal grievance procedure which can be found at:

http://www.montclair.edu/disability-resource-center/forms/#grievance

 

Student Signature ______________________________________   Date ____________________

 

REQUEST FOR HOUSING ACCOMMODATIONS

Form 3 – To Be Completed by Medical Professional

To consider this student’s request for an accommodation in the residence halls due to disability, Montclair State University requires documentation of the student’s disability from the treating clinical professional or health care provider thoroughly familiar with the student’s condition and functional limitations. 

Student name ____________________________________    Date ________________________

Diagnosis (please include diagnostic code) ____________________________________________

Treatment Plan  _________________________________________________________________

Does the student’s disability significantly limit any major life activities?  If so, please indicate the major life activities and provide details of limitations and how they relate to living in a residence hall

______________________________________________________________________________

Accommodation(s) recommended:

______________________________________________________________________________

Please describe the type, severity, and frequency of symptoms related to this disability.

______________________________________________________________________________

REQUEST FOR HOUSING ACCOMMODATIONS

Is this request medically necessary or recommended to enhance the comfort and convenience of the student? If medically necessary, please explain how the accommodation relates to the impact of the condition.

______________________________________________________________________________

If this accommodation could not be provided, what would be the medical impact on the student?

______________________________________________________________________________

This section must be completed for this form to be valid

Name _______________________________________________________

Title __________________________   Specialty ______________________

Office Address _________________________________________________

Phone _______________________________________   

License/Certification # and state of license __________________________

Signature __________________________    Date_____________________

 

Parking Policy Exception Request

 

Parking Policy Exception Request – Medical Appeal

Disability Resource Center

Webster Hall 100

Phone – 973-655-5431     Fax – 973-655-5308

­­­­­­­­­­­­­­­­­­­­

Please return completed request to The Disability Resource Center.  A decision will be made pending a review of medical documentation.

Student: Please complete top section only

Name__________________________        CWID# ________________________________

Home Address ____________________________________________________________

On Campus address _____________________     Phone number ____________________________

I understand that my personal medical information will be shared on a “need to know” basis with other University Offices. I authorize Montclair State University’s Health and Counseling Services to contact my health care provider if further information is needed.

_______________________________________________________________________

Student’s Signature                                                                                    Date

Dear Health Care Provider:

Your patient is or will be a resident student at Montclair State University who is ineligible to park on campus. 

Exceptions will only be made for students who demonstrate a compelling need for a parking exception.  A medical appeal will be considered for students who need to attend frequent (at least weekly), scheduled   (not “as needed”) medical, dental, or psychological appointments in areas not served by public transportation. 

1.  Diagnosis: ____________________________________________________________________

 

2.  Frequency of scheduled appointments ______________________________________________

 

3.  Date of next appointment ________________________________________________________

 

4.  Reasons for ready access to own transportation (cannot include “just in case”situations:

____________________________________________________________________________

 

5.  How long will the student need this level of care and frequency of visits?

_______________________________________________________________________________

 

6.  Is there anything you would like to add to further justify this request? _____________________

 

We will contact you if further information is needed.  (See signed patient release at top of page)  Thank You!

Signed: _____________________________________________       Date ____________________

                                      Health Care Provider

Please Print name _________________________________________________________________

Office Address/Stamp: _____________________________________________________________

Office Phone:  (_______) __________________

 

 

PWD Shuttle Service Request Form

 

PWD Shuttle Service Request Form

Disability Resource Center

Webster Hall 100

Phone – 973-655-5431     Fax – 973-655-5308

Please return completed request to The Disability Resource Center.

Student: Please complete top section only

 

Name _____________________________________      CWID# ______________________

Home Address______________________________________________________________

On Campus address ______________________ Phone number ______________________

I understand that my personal medical information will be shared on a “need to know” basis with other University Offices. I authorize Montclair State University’s Health and Counseling Services to contact my health care provider if further information is needed.

Student’s Signature  ______________________________  Date _____________________ 

To be completed by Health Care Provider

Dear Health Care Provider:

Your patient is requesting special transportation services from Montclair State University based upon an inability to walk or use our regular shuttle service due to temporary or permanent disability

1.  Diagnosis: _____________________________________________________________

2.  How long will this service be needed? From ____________until ____________________

We will contact you if further information is needed.  (See signed patient release at top of page)

Thank You!

 

Signed: ___________________________________Date __________________________

                          Health Care Provider

Name (please print) _______________________________________________________

Office Address/Stamp: _____________________________________________________

Office Phone:  (_____) _____________________________

 

PWD Shuttle Service Procedures

  • Shuttle service will be provided after medical documentation is received and your request approved.
  • Shuttle users must provide us with a copy of their schedule including pick up times and locations.
  • Every effort will be made to provide timely service to those whose schedules have been submitted.
  • Last minute requests can be made by calling the Shuttle Service department at (973) 655-3326.
  • Immediate service cannot be guaranteed to those making last-minute requests.

Student Name_____________________________________________________

Cell Phone # _____________________________________________________

 

 

WEEKLY SCHEDULE

PICK UP TIME

DAY

DEPARTURE

DESTINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Form

 

Registration Form

Disability Resource Center

 

Today’s Date:                                                 

 

GENERAL INFORMATION:

 

Name:                                                                                                                                ______

Student ID#:                                                             Date of Birth:                                                

Home Address:                                                                                                                              

                                                                                                                                                     

City                                                                             State                            Zip Code

Home Phone# :                                               _____   Cell Phone#: _____________________

Email Address:                                                                                                                             

DISABILITY INFORMATION:

Check all that apply (asterisk the primary disability)

 

            ADD/ADHD                                                 Deaf/Hard of Hearing

            Learning Disability                                          Blind/Low Vision

            Communication                                              Motor/Orthopedic

            Brain Injury                                                     Systemic/Chronic Medical

            Psychiatric                                                       Other                                             _____

Problems Due to Disability in Academic Settings:                                                                       

                                                                                                                                                 

_________________________________________________________________________

Accommodations Previously Used:                                                                                           

                                                                                                                                                

________________________________________________________________________

Accommodations Currently Requested: _________________________________________

________________________________________________________________________

________________________________________________________________________