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 Text Request Form
- Confidentiality and Release of Information
- Consent for Release of Information to DRC
- Grievance Procedure
- Housing Accommodation Request Form
- Parking Policy Exception Request
- PWD Shuttle Service Request Form
- Registration Form
Alternative Exam Request Form
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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 the DRC (Word)
- Consent for Release of Information to the DRC (PDF)
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.
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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
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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: _________________________________________
________________________________________________________________________
________________________________________________________________________