Center for Access and Accommodations Intake Form

Center for Access and Accommodations Intake Process

Complete this form only AFTER you have registered for classes.

Please make sure you are checking your dupage.edu email address for follow up.

Please select one of the following options; I Am:Required *

A student requesting accommodations for an ONGOING disability or health concern (ex: ADHD, Depression, Diabetes, etc)
A student requesting an exemption from a course or program prerequisite
A K-12 student/guardian requesting accommodations for a Youth or High School Program
A current student exploring the Medical Withdrawal/Appeal Process
A current student requesting accommodations for a TEMPORARY medical issue or illness (ex: broken leg, COVID, The Flu, etc)

Medical documentation WILL be requiredRequired *

If you did not or will not seek medical attention, please refer back to your syllabi for course policies related to absences and make up work. If your instructor referred you to our office, please let them know that you do not qualify for accommodations.

I will attach medical documentation to this request

I AgreeRequired *

I UNDERSTAND THAT IF I RECEIVE FAFSA FUNDING (MAP GRANT, PELL GRANT) OR HAVE ANOTHER FUNDING SOURCE, AN APPROVED REFUND MAY IMPACT MY FUNDING ELIGIBILITY OR ACCOUNT BALANCE. I AGREE THAT I HAVE SPOKEN WITH MY FINANCIAL AID REPRESENTATIVE TO UNDERSTAND HOW ANY APPROVAL WILL FINANCIALLY IMPACT ME.

I Agree Yes I Agree No

First NameRequired *

Last NameRequired *

COD Student ID (7 digits- begins with 0 or 1)Required *

BirthdateRequired *

Button, Start Date - Pick Using Date Picker Widget Button, Start Date - Clear/Reset Selected Date

Format as: two digits for month, dash, two digits for day, dash, four digits for year (yyyy-mm-dd)

EmailRequired *

Please use your College issued email address

Student’s Preferred Phone NumberRequired *

Please enter your preferred phone number in this format: XXX-XX-XXXX

Are you a Veteran or Military connected student using VA education benefits?Required *

Are you a Veteran or Military connected student using VA education benefits? Yes Are you a Veteran or Military connected student using VA education benefits? No

Are you a College of DuPage employee?Required *

Are you a College of DuPage employee? Yes Are you a College of DuPage employee? No

Are you enrolled in a program that has clinical or internship requirements?Required *

Are you enrolled in a program that has clinical or internship requirements? Yes Are you enrolled in a program that has clinical or internship requirements? No

My diagnosed disability(ies) fall into the following categoriesRequired *

Choose all that apply

If Other Please Specify

How does your disability impact you academically? Required *

What Temporary issue has occurred? Required *

What was the date range impacted by the medical situation? Required *

When did you first miss a class or a due date? When did or will you be able to return?

What accommodation or accommodations are you requesting?Required *

During what semester did the medical situation occur? Required *

What courses were or are impacted?Required *

Include course name, course number, and section number

Last date you participated in the courseRequired *

If different dates for different classes, indicate which date belongs with which course

Did you already drop the course? Required *

Did you already drop the course? Yes Did you already drop the course? No

On what date did you drop the course? Required *

Please briefly describe the Medical Situation that Occurred, including the date range that was impactedRequired *

you will have an opportunity to speak with someone directly to provide more information

Do you feel that with accommodations you could complete the course?Required *

Do you feel that with accommodations you could complete the course? Yes Do you feel that with accommodations you could complete the course? No

What accommodations do you feel would be necessary? Required *

Upload supporting document(s) (Examples: Hospital/Doctor Appointment summary, Letter from Healthcare Provider, IEP/504, disability testing, COVID positive results, etc)Required *

By submitting this request, I give consent to the College of DuPage Center for Access and Accommodations to receive and confidentially store all information and documentation I have chosen to provide. I understand that the Center for Access and Accommodations may verify to other areas of the college that I am eligible for accommodations, however it is my responsibility to inform my instructors and other relevant individuals or departments of my approved accommodations. I am also responsible for informing the Center for Access and Accommodations of any changes to my needs or of any assistance I need coordinating my accommodations. I understand that my disability related needs must be clearly communicated to all relevant parties in a timely manner, and that accommodations are not retroactive. I, the student requesting accommodations, declare the truthfulness of the information provided on this form and the attached documentation.

Drop files here to upload