Berkeley College Office of Disability Services

Berkeley College · Office of Disability Services

Application for Disability Services and Accommodations Cover Page

BERKELEY COLLEGE

Office of Disability Services

Application for Disability Services and Accommodations

The Americans with Disabilities Act (ADA) and other federal and state laws require colleges to provide “reasonable accommodations” of disabilities (modifications or adjustments designed to enable a qualified person with a disability to participate in a College program or activity). This process begins upon the student’s request. The types of accommodations available under Berkeley's Disability Policy are based upon the individual's documented disability and the College's ability to provide assistance without incurring undue burden or fundamentally altering its programs, facilities, policies or activities.

Students who should submit this form are:

• Prospective students seeking accommodations during Admissions process (e.g. extended time on Admissions Exam) or for a campus visit

• Admitted students who will be attending Berkeley College

• Current students who have not applied for disability services and/or accommodations at Berkeley College

• Students requesting housing accommodations and/or the use of a service animal in housing

• Current students with a temporary disability

Students who should NOT submit this form are:

• Students seeking support on the basis of a short/acute illness (e.g. seasonal flu). In such instances, students should contact their advisor for assistance.

Sections to be completed by the student: Sections to be completed by a

Health Care Provider:

1. Student InformationX. Health Care Provider Information
2. Academic Information
3. Referral Information
4. Previous School Information
5. Disability Information and Documentation
6. Student Narrative/ Statement on Impact
7. Accommodations and Services
8. Confidentiality and Release of Information
9. Student Information for Health Care Provider

Individual requests for accommodations may be referred to the specific campus ADA/Section 504 Coordinators: [NY students] Adam Rosen, Psy.D., 212-986-4343 ext. 4216 or ; [NJ students] Sandra Coppola, Ph.D., 973-278-5400 ext. 1320 or ; [Online students] Katherine Wu, Ed.M., LMHC, LPC, 973-405-2111 ext. 1394 or . In addition, each individual campus has a Disability Services representative via the Personal Counseling Office. These Personal Counselors work with the ADA/Section 504 Coordinators for the purpose of reasonably accommodating students with disabilities. A student seeking accommodations must schedule an appointment with either the above-stated ADA/504 Coordinators, or a campus Personal Counselor, in order to submit an Application for Disability Services and to confirm requested accommodations. Contact information for the College Personal Counselors can be found on the Berkeley College Health and Wellness website at: http://berkeleycollege.edu/10231.htm . Select “Contact Information” from the drop-down menu.

Berkeley College · Office of Disability Services

Application for Disability Services and Accommodations Cover Page

· Office of Disability Services

Application for Disability Services and Accommodations- Student Information

Today's Date:______Semester ______Year ______

I. Student Information

Note: All email communication from Office for Disability Services will be sent to your Berkeley College

e-mail address once assigned by the college.

Student: ______DOB: ______Student ID#: ______

Address: ______

Phone: ______Berkeley College E-mail: ______

Campus Location:______

Check one of the two options below:

I am new to disability services at Berkeley College. This is my first application for disability services and/or accommodations.

I am returning to the office of disability services.

ADA Coordinator: ______

When did you first receive services? Indicate semester and year______

Name of Berkeley College Academic Advisor:______

Telephone Number:______

E-mail Address:______

Are you currently receiving tutoring services from the Center for Academic Success? Yes No 

Are you currently receiving services from the New York or New Jersey state Vocational Rehabilitation System (ACESS-VR) for a documented disability?

Are you currently receiving services for a documented disability from New York, New Jersey, or other sate Vocational Rehabilitation Services? Yes  No 

· Office of Disability Services

Application for Disability Services and Accommodations- Student Information

 New York

State Commission for the Blind and Visually Handicapped

Adult Career and Continuing Education Services – Vocational Rehabilitation (ACCES-VR)

 New Jersey

Commission for the Blind and the Visually Impaired

New Jersey Division of Vocational Rehabilitation Services

 Other state ______

Berkeley College · Office of Disability Services

Application for Disability Services and Accommodations- Student Information

If so, please indicate the following information regarding your state Vocational Rehabilitation counselor:

Name of Counselor: ______

Address: ______

Telephone Number:______Fax Number: ______

E-mail address: ______

Are you currently receiving services for a documented disability from a community based agency that provides services for people with disabilities? Yes  No 

Name of Agency ______

Address: ______

Telephone Number:______Fax Number: ______

E-mail address: ______

II. Academic Information

First semester (or anticipated) at Berkeley College______

Anticipated graduation date(month/year)______

With which school/s are you affiliated: Larry L. Luing School of Business® · School of Graduate Studies School of Health Studies · School of Liberal Arts · School of Professional Studies

Degree or Certificate Program:______

Semesters completed at Berkeley College to date: ______

Will you live on campus this semester? Yes No 

Check all that apply:

 I am an International student

 I am an athlete (specify team affiliation)

 I am a military veteran (specify VA affiliation if applicable):

III.Referral Information

Please indicate how you heard about Disability Services (check all that apply):

Berkeley College Website Berkeley College Student Family Member Professor

Academic Advisor/Dean Counseling Services ADA Coordinator Student Orientation

 Admissions Associate Other:______

IV.Previous Schools and Accommodations

Previous school/s attended / Dates attended (from-to) / List all approved disability accommodations and services from previous school/s

V.Disability Information & Documentation

Specify your disability type(s) - check all that are applicable:

 Physical or Mobility PsychologicalChronic Medical Condition

Specify:______Specify:______Specify: ______

Deaf or Hard-of Hearing Blind or Low Vision Attention Deficit/Hyperactivity Disorder

Traumatic Brain InjuryLearning DisabilityOther:______

Primary disability type for which you are requesting accommodations: ______

Date of diagnosis/es:______

Please provide information about the disability documentation you will be submitting to our office.

Note: you are responsible for ensuring your documentation meets the Office of Disability Services

documentation guidelines.

Name of Provider on Documentation:______

Dates of Documentation (month/year): ______

Type(s) of Documentation:

 Learning Disability, AD/HD, Psycho-Educational, or Neuropsychological Evaluation

 Disability Verification Form

 Letter from Treatment Provider

 Letter from previous school confirming approved disability accommodations

Other:______

Only complete the section(s) below that apply to your documented disability(ies). After you have completed the appropriate section, move on to Section VI.

Part A: Deaf or hard-of-hearing Part B: Visual disability or blind Part C: Physical/mobility disability, or temporary injury

A. To be completed only by individuals with a hearing disability or who are Deaf:

Do you wear hearing aids or cochlear implants?  yes no If yes, check all that apply:

Behind-the-ear hearing aids: Do they have Direct Audio Input (DAI)?  yes  no

In-the-ear hearing aids In-the-canal hearing Cochlear implant

 Cochlear implant - body worn processor My device has telecoils

Have you used a neckloop with telecoils?  yes no

My device has a M-T (microphone-telecoil) switch

Do you or have you used an FM system/assistive listening device in the past?  yes no

If yes, please specify type (brand, model):

If yes, how does/did sound get to your ear?:

 neckloop earphone (in the ear)  cochlear implant  headphone (over the ear)

Do you use captioned media? yes no

What means of expression and receptive communication do you use? Check all that apply:

Oral Communication Speech Reading American Sign Language Signing Exact English

Speech-to-text transcription (e.g. CART, C-Print) - Please specify your preferred type:

Other (specify):

B. To be completed only by individuals with a visual disability or who are blind:

Visual Acuity (if applicable):Right Eye:Left Eye:

Degree of Blindness:  Total  Light PerceptionForm Perception

Travel Aids: Cane Service Animal Other:

Do you use Assistive Technology? Specify type(s):

Do you use alternate format reading materials? yes no

If yes, indicate your preferred alternate format from the following:

Large Print Specify font size and type (e.g. 20 point bold, sans serif font):

If you use large print, specify whether it is used for visual subjects only (e.g. math, science, art) or for all subjects:

 Electronic Format. Specify file type (e.g. Word, DAISY, audio file, accessible PDF):

Braille

Other (specify):

C. To be completed only by individuals with a physical or other mobility disability, or temporary injury:

Which, if any, of the following mobility aids do you use?

Prosthesis (specify): BracesCrutchesCane

Manual Wheelchair  Motorized wheelchair/scooterOther (specify):

Do you have a state issued handicapped parking permit? yes no

Do you use stairs? (If so, specify general number tolerable):
VI. Student Narrative/Statement on Impact

The purpose of this section is to serve as a supplement to the disability documentation you submit by way of self-report. In this section, you are prompted to describe the limitations you experience and how those limitations impact your academic performance/participation in Berkeley College's programs/campus and outside the classroom. This information helps us better understand your reason(s) for requesting accommodations at Berkeley College. Should you need more room to complete this section, please feel free to include an addendum.

a) List the specific cognitive/academic difficulties you experience related to your disability (e.g. reading, writing, concentration, memory, time management, note-taking, etc.) that may impact your ability to complete your coursework or other program requirements.

b) Please describe your academic performance at Berkeley College thus far or from your most recent school.

c) Provide any information about your program that you feel is important and relevant to your accommodation request.

d) How does your disability affect you in your everyday life, daily activities, getting around campus, social interactions, outside the classroom?

e) How have accommodations been helpful to you in the past? If you are requesting accommodations for the first time, please describe the reason(s) accommodations were not needed previously.

VII. Accommodations and Services

Please specify the accommodations you are requesting. Disability Services will consider your request in light of your disability as described in your supporting documentation, and other information provided to Disability Services, as well as the requirements of your specific academic program.

Campus Accommodations:

Elevator and lift access - specify location(s):

Locker on campus - specify location:

Orientation and Mobility Training

Accommodations for campus visit - date of visit:

Specify accommodations:

Classroom Accommodations:

Note-taking services

Permission to use laptop for note-taking in class

Permission to audio record lectures

Accessible classroom and furniture - specify your need:

Other classroom accommodations:

Exam Accommodations:

Extended time for in-class exams and quizzes Amount requested: minutes per hour

 Distraction reduced environment for quizzes and exams

Scribe for exams (answer recorded/written for student)

Reader for exams

Use of computer for exams - specify: MAC  PC No preference

"Stop the clock" rest breaks: Up to 15 minutes per hour of exam time

Accommodations for Admissions Exam or other placement/waiver exams (for any Berkeley College school). Specify Exam(s):

Specify Accommodations (if different from above):

Other exam accommodations:

Academic Accommodations:

Modifications to course requirements

Specify course/request:

Priority Registration

Training to use Assistive Technology Programs such as:

JAWS for Windows, Kurzweil 3000, ZoomText, and Dragon Naturally Speaking

Other academic accommodations:

Communication/Technology Accommodations:

Sign-language interpreters

Assistive listening devices (e.g. FM or Infrared systems)

Real time captioning (CART)

Captioned videos, podcasts, or other media

Assistive Technology

Specify type:

Textbooks in alternate format

Electronic text- Microsoft Word format  Electronic text- structured PDF

Large print (specify font sizes and styles):

Audio format (specify):

 Other:

Other Accommodations:

Other accommodations - specify:

Should you have questions about completing this form, about your disability documentation, or if you wish to learn more about the application process, you are welcome to email the Director of Disability Services at

Berkeley College · Office of Disability Services

Application for Disability Services and Accommodations- Confidentiality and Release of Information

VIII. Confidentiality & Release of Information

Confidentiality:

Berkeley College acknowledges that student disability records contain confidential information. A student's disability records are maintained in a confidential file with Disability Services (DS). Documentation concerning disabilities is separate from the student's general academic record. Eligibility and receipt of accommodations will not appear on a student’s academic transcript.

Disability-related information provided to DS is considered an Education Record; therefore it falls under the protection of the Family Educational Rights and Privacy Act (FERPA). FERPA permits DS to share information about the impact of a disability and accommodation eligibility with other Berkeley College school officials who have a legitimate educational interest. A “school official” includes, but is not limited to, ADA Coordinators, faculty and instructional staff, residence life staff, academic deans and advisors, career services, public safety and counseling. “Legitimate educational interest” means the school official needs to review an Education Record or information derived therefrom in order to fulfill his or her professional responsibilities. Generally speaking, faculty and college staff outside the Office of Disability Services do not have the right or need to view diagnostic information related to your disability; rather, they might need to know your accommodation eligibility and your accommodations. Sharing this “need to know” information with school officials does not require student consent under FERPA.

______Please initial here to evidence your understanding of FERPA in the disabilities context.

However, student disability related medical records may be protected by separate state and/or federal laws. To the extent that a state or federal law requires your consent before DS shares disability related information with school officials with a legitimate interest in the information, your signature below authorizes that sharing.

This authorization will be deemed effective for the entire period you are enrolled at Berkeley College. This authorization can be revoked if and when you submit a written request to do so directly to the Director of Disability Services. This authorization begins at the time this form is submitted and applies during times away from Berkeley College including, but not limited to, breaks between semesters, medical leave, studying abroad, etc.

Name of Student (Please print)______

Signature of Student______

Student ID# ______Date ______

Disclosures to Third Parties

Written consent IS required for the release of disability related records to non-school officials. Berkeley College staff will provide disability documentation to a specified individual or entity after a student has provided written authorization or consent. Students are responsible for specifying what information they wish to share and with whom via a FERPA Authorization to Release Student Records form found here: https://transforms.berkeleycollege.edu/iFiller/iFiller.jsp?fref=6ea5fc31-b08f-4290-b67b-a9cba033d8a6

For more information on the privacy and release of student Education Records, please refer to the College FERPA Policy found here: http://berkeleycollege.edu/files_bc/FERPA_Notice_Berkeley_1099.pdf

Berkeley College · Office of Disability Services Page 1 of 16

Application for Disability Services and Accommodations- Health Care Provider Information

IX. Student Information for Health Care Provider

Students: Review instructions and fill out information below before giving to your health care provider. (Please Print Legibly or Type)

Berkeley College · Office of Disability Services Page 1 of 16

Application for Disability Services and Accommodations- Health Care Provider Information

Full name: ______

Student ID#:______

Home phone: (______) - ______- ______

Cell phone: (______) - ______- ______

Work phone: (______) - ______- ______

Best number to reach you:______

Best days/times to reach you: ______

Berkeley College · Office of Disability Services Page 1 of 16

Application for Disability Services and Accommodations- Health Care Provider Information

Instructions

The outline below has been developed to assist you in working with your treating or diagnosing healthcare professional (psychiatrist, psychologist, counselor, therapist, social worker, medical doctor, optometrists, speech-language pathologists etc.) to obtain specific information. This information will be used to evaluate eligibility for academic accommodations.

A. The healthcare professional(s) conducting the assessment and/or making the diagnosis must be qualified to do so. These persons are generally trained, certified, or licensed to diagnosis medical conditions.

B. All parts of the form must be typed and completed as thoroughly as possible. Inadequate information and incomplete answers will delay the eligibility review process by necessitating follow up contact for clarification.

C. The healthcare provider should attach any reports that provide additional related information (e.g. psycho-educational testing, neuropsychological test results, medical records, etc.). If a comprehensive diagnostic report is available that provides the requested information, copies of that report can be submitted for documentation in addition to this form.

D. The information provided by your healthcare provider will be kept in your file at the office of the ADA Coordinator and the Director of Disability Services, where it will be held confidential. This form may be released to you at your request. In addition to the requested information, your healthcare provider may attach any other information he/she thinks would be relevant to your academic adjustment/accommodation.

1. Healthcare Provider Information

Filled out by Healthcare Provider and returned to student