NORTH CAROLINA A&T STATE UNIVERSITY
DISABILITY SUPPORT SERVICES
REQUEST FOR SERVICES
The Disability Support Services Office has been designated on campus to assist students with disabilities. In order to provide this assistance it is necessary to identify students with disabilities in a timely manner. Therefore, we are asking your cooperation in completing this questionnaire if you require services. Please remember that any information you provide is strictly voluntary. This voluntary self-identification allows North Carolina A&T State University to the support services needed to facilitate your learning. This information will be kept in confidence.
Please complete the following:
Student Banner ID# ______Student PIN # ______
Name: ______
(Last Name) (First Name) (Middle Initial)
Date of Birth:______Email Address: ______
Local / Campus Address:______
Home Phone: ______Cell Phone: ______
What is your classification at NC A&T SU? ______
What is your major at NC A&T SU? ______
What is the nature of your disability? (Check all that apply)
___ADD/ADHD
___AutoImmune Disease
___Blindness
___Cognitive Disorders
___Communication
___Deafness
___Hard of Hearing
___Head Injury
___Learning Disability
___Mobility Impairment
___Muscular Disorders
___Neurological Disorder
___Psychiatric
___Sickle Cell Anemia
___Visual Impairment
___Others Heath Related (specify: ______)
Limited major life activity involved. (Check all that apply)
___Participating in physical activities
___Understanding spoken language
___Climbing Stairs
___Learning
___Talking
___Walking
___Hearing
___Math
___Reading
___Writing
___Other, please list ______
Prescription Medications taken regularly: ______
______
What accommodations or services do you need while you are in school?
______
I certify that the information above is accurate.
I authorize the Disability Support Services Office at North Carolina A&T State University to disclose to faculty and/or staff members information regarding my disability and need for accommodations.
This information may be used to evaluate the need for educational services and/or plan an educational program. The use or release of this information is limited to purposes directly connected with my educational program.
I understand that my records are protected under confidentiality legislation and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand I may revoke this consent at any time except to the extent that action has already been taken. This authority expires with graduation unless otherwise specified.
I also understand that the request for services MUST be made each semester or summer session.
Student’s Signature: ______Date: ______
Please return this completed data sheet to:
Disability Support Services
North Carolina A&T State University
1601 E. Market Street
Murphy Hall, Suite 01
Greensboro, NC 27411
North Carolina Agricultural and Technical State University is committed to equality of educational opportunity and does not discriminate against applicants, students, or employees based on race, color, national origin, religion, gender, age, or disability.