Montclair State University

DRC Forms

DRC FORMS ARE AVAILABLE HERE IN THREE DIFFERENT FORMATS:

1. Forms are available below in HTML so that they may be read by screen readers.

2. Forms are available as WORD documents and can be downloaded, printed, completed by hand and submitted in person or by mail to the DRC office.

3. Forms are also available as PDF AUTO-COMPLETION documents. You can download the form, complete the information, print the form and then send the information electronically to the DRC office.

YOU MUST HAVE ADOBE ACROBAT READER 7.0 TO OPEN THESE FILES! Acrobat Reader 7.0 is available FREE for Windows XP at: http://www.adobe.com/products/acrobat/readstep2.html

and is available FREE for the MAC at: http://www.adobe.com/support/downloads/product.jsp?product=10&platform=Macintosh

TO USE THE NEW AUTO-COMPLETION FORMS:

1. Open the appropriate DRC PDF form.
2. Select the hand tool and click inside the grey text field. Type the appropriate information.
3. Note that forms requiring a social security number are encrypted for security.
4. Press TAB to move forward or backward or SHIFT+TAB to move backward among the form fields.
5. When you are finished filling out the form, click the SUBMIT FORM button at the top of the PDF page and follow the instructions. Your information is sent via email to the DRC office.
6. If you want to print the completed form, click the PRINT FORM button at the top of the PDF page.

Form Contents:

ALTERNATIVE EXAM REQUEST

CONFIDENTALITY AND RELEASE OF INFORMATION

EQUIPMENT LOAN

GRIEVANCE PROCEDURE

GUIDELINES FOR DOCUMENTATION OF A.D.D. AND A.D.H. DISORDER

REDUCED COURSE LOAD

REGISTRATION FORM

RLEASE OF INFORMATION TO DRC

Alternative Exam Request Form

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 (Morehead Hall 305)

____Sent by e-mail (addresses:_____________________________________)

____Sent by FAX (655-5308)

____Delivered by Student in sealed, signed envelope

Completed Exam Will Be:

____Delivered by DRC to the instructor’s office

____Picked up by the instructor at DRC office (Date & Time)

____Delivered by Student in sealed, signed envelope

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

____Instructor’s Signature Date

If you have any questions or concerns, please contact Linda Smith at 655-5431 or smithli@mail.montclair.edu, or Angie Wallerich Millman at 655-4432 or wallericha@mail.montclair.edu TOP

 

Confidentiality and Release of Information

The office of 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 DRC to facilitate accommodations on my behalf, they may need to consult with other University personnel. Circumstances that may warrant such disclosure include: requests 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 (check YES or NO):

Instructors YES___NO___

Residence Life YES___NO___

Financial Aid YES___NO___

Registrar’s Office YES___NO___

Academic Advisement YES___NO___

CADA YES___NO___

CAPS YES___NO___

UH&CS YES___NO___

Parent(s) or Guardian(s) YES___NO___

Other: YES___NO___

I furthermore release all parties stated herewith 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):______________________________ SSN:__________________

Signature:_________________________________ Date:_____________TOP

 

Equipment Loan

BORROWER IDENTIFICATION:

Name___________________________Social Security #__________________

Address_________________________________________________________

Phone Number___________________________________________________

EQUIPMENT_____________________________________________________

DATE BORROWED____________________ DUE DATE___________________

I agree to return the above named equipment to the Office of Disability Resource Center on or before the due date. I understand that failure to return the equipment will result in a hold being placed on my student account.

Signature____________________________________ Date_______________

For Office Use Only:

Date of return:___________________TOP

 

Grievance Procedure

• 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 Disablitity 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 Director of Health and Wellness, 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 Ombudsperson.
• 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 office of Disability Resource Center.

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

Name_______________________________Social Security #______________

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:

_________________________________________________________TOP

 

Guidelines for Documentation of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder

This student is seeking academic accommodations through the office of Disability Resource Center at Montclair State University . To ensure provision of reasonable and appropriate accommodations for students with Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder, Montclair State University requires documentation of disability and information from a qualified medical professional that provides the following: (1) the diagnosis of ADD/ADHD; (2) a description of attention difficulties and functional limitations in an educational setting; (3) an indication of the severity and longevity of the condition; and (4) information about medications prescribed and the side effects of these medications. To facilitate the gathering of the information, we ask that you respond to the following questions:

1. Date of diagnosis: ___/___/______

2. Date of last contact with student: ___/___/______

3. What procedures were used to assess/diagnose /ADHD?

________________________________________________________________

4. Describe the symptoms that meet the criteria for diagnosis with approximate date of onset.

________________________________________________________________

5. Describe the severity of the condition and this student’s functional limitations in an educational setting:

________________________________________________________________

6. Is this student taking medication? If yes, please list medication(s), indicate date of initial prescription and possible side effects of the medication: Please include any information that you feel is relevant in determining appropriate accommodations for this student:

________________________________________________________________

________________________________________________________________

Signature: …………………………………………………………………………………

Name and Title: ___________________________________________________ TOP

 

Reduced Course Load Approval Form

Student’s Name_____________________ Social Security _________________

The above named student has a documented disability that has been reviewed by the Director of Disabilities Resource Center. The impact of the disability has been reviewed in the context of his/her proposed schedule. It has been determined that a reduced course load is a reasonable accommodation under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act.

This student will be registering for credits for the semester. The accommodated course load of credits will be treated as his/her minimum credit load for full-time status and entitle him/her to all rights, privileges, benefits, services and responsibilities of a full-time student.

I have explained the potential impact that the reduced credit load may have on financial aid and the completion of his/her degree.

Director, DRC………………………………………………...... Date_____________________

I understand that taking a reduced course load may negatively impact progress toward graduation and eligibility for federal financial aid.

Student Signature…………………………………………................Date_____________________

Cc: Registrar, Financial Aid, Bursar, Student’s Advisor, Dean of Students, Residence Life, if applicable, Student, File TOP

 

Registration Form

Today’s Date:__________________________

GENERAL INFORMATION:

Name: _______________________________Social Security ______________

Date of Birth:______________________

Home Address:

City:__________________________________State:____ Zip Code:________

Home Phone Number: Work/Cell/Pager #:

School Address (if applicable):

Street Address___________________________________________________

City:_____________________State:___School Phone Number_____________

Email Address:___________________________________________________

Major:__________________________ Credits Earned: __________________

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:

____Adaptive Computer Equipment (Specify:_________________________ )

____Alternative Testing (Specify:__________________________________ )

____ASL Interpreter ____Assistive Listening Devices

____Books on Tape ____Braille Text

____Extended Time for Tests ____Note Taker

____Reader ____Scribe

____Taped Lectures ____Other (Specify: ____________________________)

OTHER SUPPORT SERVICES:

DVR Client:___yes___no DVR Status: ___receiving services ___eligibility pending

___case closed ___inactive ___not eligible

DVR Counselor:___________________________ Phone #:_______________

Commission for the Blind:___ yes___ no

Contact:_________________________________ Phone #:_______________

Other:___________________________________ Phone #:______________

I am aware that the University does not provide personal devices, such as wheelchairs; individually prescribed devices, such as hearing aids; or services of a personal nature, such as assistance in eating, toileting, or dressing. Should I require these services, it is my responsibility to provide for my own assistance.

I have received the DRC handbook containing all departmental policies and procedures. I understand that I will not be eligible for services if I do not provide documentation of a diagnosed disability, do not have a diagnosed disability, or do not follow policies and procedures of the office of Disability Resource Center.

Name (print):_____________________________ SSN:___________________

Signature:________________________________ Date:______________TOP

 

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: _______________________________________SSN:____________________

Address (street): ______________________________________________________________

(city) ___________________________ (state) _______ (zip) ____________

Phone Number: _______________________________________________________________

Physician’s Name: _____________________________________________________________

Address (street): ______________________________________________________________

(city) ___________________________ (state) _______ (zip)_____________

Phone Number: _______________________________________________________________

BACK TO TOP

BACK TO DRC MAIN PAGE