Confidential Intake and Accommodation Request

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Student Information

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Student Self-Disclosure

Do you wish to disclose you have a disability?Required
Do you wish to request accommodations for your disability?Required
Would you like to register to vote?Required

Disability Information

Self-Assessment

Please select any of the major life activities listed below that might be affected as a result of your disability/impairment.

Accommodation Request

Have you received accommodations for this disability in the past?

Authorization to Release Information

Information to be released/disclosed

I request and/or authorize the Office of Disability Services (ODS) at Virginia Western Community College (VWCC) to release/disclose/discuss the following:

I authorize VWCC to release and disclose information to:

I authorize VWCC to release and disclose information to:

In order to have information released via phone, fax, or e-mail to the Party to Whom Information will be Released listed above, a personal identification number (PIN) of at least four-digits must be assigned by the student. The Party to Whom Information will be Released must identify this PIN number to receive student information.

By signing, I consent to the release of the information above to the individual(s) listed above:

Statement of Confidentiality

Virginia Western Community College (VWCC) Office of Disability Services (ODS) is committed to ensuring that all information and communication pertaining to a student's disability is maintained as confidential as required or permitted by law. The following guidelines about the treatment of such information have been adopted by VWCC Office of Disability Services. These guidelines incorporate relevant state and federal regulations.

1. Information submitted to the ODS is protected by the Family Educational Rights and Privacy Act (FERPA).

2. Information regarding your disability is confidential. No one will have immediate access to student files in CDS except the appropriate staff of ODS.

3. A student's file maybe released pursuant to a court order or subpoena. Students will be notified of this prior to the release of information. This information will be released in accordance with federal and state laws.

4. If a student wishes to have information about his/her disability shared with others within or outside the college, the student must provide written authorization to ODS by completing the Authorization to Release Information form. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released.

5. Student's ODS information will remain on file for 3 years, following the student's last semester of enrollment. After this time, their file is permanently and confidentially destroyed.

6. A student has the right to review his/her own ODS file with reasonable notification, and may request an amendment to ODS records that are believed to be inaccurate. *Please note, this would not include diagnostic information submitted to the office by the student, physician or clinician.

7. Any documentation submitted to ODS verifying a student's disability will NOT be released/returned to the student, or to any other third party after submission. Students should ensure they retain original copies of their documentation for their records.

I have been informed of the policy regarding confidentiality and the release of information regarding my ODS file.

Documentation

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It is the policy of the Virginia Community College System and Virginia Western Community College to promote and maintain equal employment and educational opportunities without regard to race, color, religion, disability, sex, sexual orientation, gender identity, ethnicity, marital status, pregnancy, childbirth or related medical conditions, including lactation, age (except when a bona fide occupational qualification), status as a veteran, national origin, or other non-merit factors. For further information, contact Hillary Holland, Disability Counselor/ADA Coordinator. Her office is located in the Student Life Center, Room S207; telephone at 540-857-6488; email hholland@virginiawestern.edu TTY 711