ACCESSIBILITY SERVICES

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Office of Accessibility Services

Office of Accessibility Services

Student Intake Form

Please complete the form below.

"*" indicates required fields

Step 1 of 8 – Disability Services – Student Intake Form

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Part A: Personal Information

Today's Date*

MM slash DD slash YYYY

First Name*

Last Name*

M.I*

PCCC Student ID#

Mailing Address

Apt

City*

ZIP Code*

State*

PCCC Email Address*

Phone

Parts B: Education and Academics

Major

Preferred Campus

Passaic

Paterson

Wanaque

What is your educational goal?

High School or Equivalent Completed

High School Diploma

GED

Other

Name of HS

Year

MM slash DD slash YYYY

Year

MM slash DD slash YYYY

Other

Completed FAFSA online?*

Yes

Are you a Trio/SSS student?*

Yes

Are you a Veteran?*

Yes

Have you registered for classes?*

Yes

Taken the Accuplacer (placement test)?*

Yes

Are you an EOF student?*

Yes

Do you work with any of these New Jersey state agencies?*

CBVI

DDD

DDHH

DMHS

DVRS

None

Other

Other*

Parts C: Disability Information

Disability Type

ADD/ADHD

Learning Disability

Mobility/Physical Disability

Psychological Disability

Visual Impairment

Hearing Impairment

Medical/Chronic Health Condition

Neurological Condition

Other

Other*

Academic Challenges:*

What academic accommodations do you think you will need for your academic coursework?*

List any current medications and side effects that could affect your academic success*

Emergency Preparedness

Will you require assistance in an emergency evacuation?*

Yes

Can you go up/down stairs?*

Yes

Do you require use of an elevator?*

Yes

Supporting Documentations

Please scan your supporting documentation to [email protected]. Below are suggestions for scanning.
Methods of scanning documents to submit to ODS:
Free Scanning Apps

CamScan
Adobe Scan
Microsoft Office Lens
OR
You can take pictures of your documents directly from your phone. Please take clear pictures so that the text is recognizable.

Release of Information*

By signing this release, I acknowledge that the professional staff of the ODS has my permission to discuss my overall academic performance and my specific academic needs, including the nature and extent of any disabilities that I have, with my instructors, advisors, counselors, and other appropriate college officials in all matters relating to my access to academic programs and services at PCCC.

Release of Records*

Graduation/Transfer: ODS Records Released to Student*

Please click Next if you are student or Parent filling this form

Click on the Submit button below to send the filled form to D officials.

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Phone

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Contact Us

Office of Accessibility Services

Phone: (973) 684-6395
E-mail: [email protected]

Main Campus -Paterson
Memorial Hall M244
(across from the Testing Center)

Passaic Academic Center
PAC – Room 218
Students are met by appointment.
Check with Main Desk for room location.

Wanaque Academic Center
WAC – Room 117
Check with the Main Desk for room location.