Public Accommodation Request

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Student Information

Please note: medical documentation and John Jay ID upload are required to complete this intake form.

Please use your university issued email address
How do you travel to campus?
Check all that apply
Are you registered to vote?Required

How You Got to Know Us

Agency Sponsorship
Check all that apply
Are you a CUNY Leads student?

Veteran Information

Are you a dependent of a veteran?
Have you ever been enlisted in any branch of the US military (Active Duty, Veteran, National Guard, or Reserve)?
Did your military service include traumatic or highly stressful experiences, which continue to affect you?

Enrollment/Academic Status

Are you a transfer student?

Disability-related Information

{"display_name":"My diagnosed disability falls into the following category","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}
Check all that apply
{"display_name":"I have difficulty","hidden_field_name":"ms_field_2","init_id":"ms_field_2","init_link":"","has_autocomplete":false,"has_hierpicklist":null}
Upload supporting document(s)Required

Forms to Upload - Checklist

1] Medical Documentation - Please upload either an 504 Plan, IEP or Medical Provider form. Please make sure the file type is appropriate (either ending in PDF or docx for MS Word and jpg for a picture) 

2] John Jay Photo ID - Please provide a copy of your John Jay ID and make sure to save as PNG or JPG (Note: Apple file type is HEIC and we do not use that file type)

Assistive Technology & Alternative Textbooks

What assistive technology/software/textbook formats do you use?
Check all that apply

Policy on Confidentiality

General Rule: 

Accessibility Services is required by law to maintain student confidentiality. All requests for accommodations and all supporting information are considered confidential.

The Family Educational Rights Privacy Act (FERPA) regulates how Accessibility Services discloses the documentation and records that the office maintains. Under this federal act, the student must provide written consent before Accessibility Services can release any disability documentation or records. 

An Exception to the Rule:

Under FERPA, Accessibility Services is permitted to release information to any college official who has a “legitimate educational interest.”

What does this mean?

A college official, acting in the student's educational interest, who needs the information for administrative, counseling, supervisory, academic, or student support purposes may request student information from Accessibility Services. We will only share information on a “need-to-know” basis. The office will carefully consider the student’s desire for privacy before disclosing any information.

FERPA also allows students to inspect and review their files maintained by Accessibility Services. Students have the right to challenge any information contained in the files that is incorrect or misleading and to request an amendment to this misinformation.

Signature

I have completed the Application for Accommodations as thoroughly and accurately as possible. I have read and understand Access-Ability Services’ policy on confidentiality

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