Self-assessment and DSS Accommodations Questionnaire

Form Instructions

Completing this form is part of the initial request for academic accommodation. However, completing this form does not guarantee that you will be provided an accommodation. You MUST provide professional documentation to support your disability to qualify for academic accommodation. In addition, you MUST also schedule an intake appointment with our office to discuss your request.

Student Information

Seminole State ID:

DOB:

First Name:

Last Name:

Address:

Phone Number:

Alternate Phone:

Seminole State Email Address:

Other Email Address(es):

Emergency Contact:

Emergency Contact Phone:

Disability Related Information

Please answer the following questions about your disability and how it may impact your ability to learn, attend or participate in college.

Please indicate your diagnosed disability:

Support Services/Academic Adjustments

List of the previous accommodation received:

Other comments or concerns:

Confidentiality

BY CHECKING THIS BOX, I understand that the information shared with the Disability Support Services Office can be shared with others at the college on a "need-to-know" basis and otherwise will be kept confidential unless disclosure is authorized by me or required by law.

BY CHECKING THIS BOX, I acknowledge I have read and understand the Student Responsibilities (what I need to Know) page.

BY CHECKING THIS BOX, I acknowledge and certify that the information I have provided is true and accurate.

Date:

Transferring and Concurrent Students

Your approved academic accommodation is VALID for Seminole State College of Florida only. Please check with your transfer college or university regarding their disability support policies and procedures several months before you plan to transfer. Accommodation does not transfer from school to school.

Certification Test and/or Industry licensing exams

If your degree requires a certification exam or license examination such as GED, NCLEX, State Officer Certification Examination (SOCE), etc., you will need to follow their specific procedures to request accommodation for that particular examination with the governing agency.

Voter Registration

Do you want to register to vote or renew your registration?

Yes

If you answered yes, you can visit any DSS office to receive a voter registration form.

Contact

General Information
dss@seminolestate.edu
Sanford/Lake Mary - 407.708.2110
Altamonte Springs - 407.404.6005
Oviedo - 407.971.5114
Text for DHH - 321.296.9844
Fax - 407.708.2484

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Self-assessment and DSS Accommodations Questionnaire

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