Student Self-Disclosure Form

* indicates a required field

Student Information

Dear Student: Please submit this form if you are seeking to register with the Office of AccessAbility Services (OAS) under a documented disability.
Please use your university issued email address
Month/Year
Do you live On Campus?Required
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Student Status
Check all that apply
Are you a Transfer Student?Required
Do you require the use of an elevator? Required
Do you require the use of handicap push plates? Required
In the event of an emergency evacuation, some students may need assistance due to the nature of their disability. Please check if you would like assistance evacuating or if you decline assistance.

Medications & Treatment

Do you experience side effects from your medication which might impact your academic life?Required
Do you have any allergies to medications? Required

Self-Report Ratings- How does your disability affect you as a student?

Please check the level of severity in each area:
In Class:
Academic Evaluations:
Out of Class:
Social:

Disability Information and Accommodations History & Request

AccessAbility Services staff want to remind students with medical disabilities that the OAS does not provide Eastern staff, faculty, or students with information regarding your medical condition, or how to care for you in case an urgent medical issue occurs.

It is your responsibility to communicate this information to the individuals around you, should you deem it appropriate. Please understand that if an event occurs in which you need urgent or emergency medical care, you or a person with you should contact 911.

Did you receive disability-related support in high school? Required
If you have no other information to share, please type NA
Are you currently in counseling or therapy?Required

Documenation and Signature

If you have documentation of disability, please upload it here.Required

If you do not have documentation, or are unsure what to submit, please refer to the following resources:

Documentation Guidelines

Documentation of Disability Forms by accommodation request

Authorization To Release Or Obtain Information

The Office of AccessAbility Services (OAS) takes seriously its obligation to preserve confidentiality of student information as required by applicable federal and state laws and regulations and by Eastern Connecticut State University’s various policies and procedures. OAS also strives to provide the most efficient service possible. In order to balance these interests, OAS requires student to designate in advance any person to whom their confidential information and records may be released/shared, or from whom confidential information or records may be obtained.

I make the following authorizations regarding the release of information pertaining to me for the purpose of assisting me at ECSU, as well as determining reasonable and appropriate accommodations. I understand that records and information concerning my disability and/or requests for accommodations are protected under law and cannot be released to anyone outside the university without my expressed written consent unless otherwise permitted or required by law. As a result, no such disclosure will be made, except in the event of a medical emergency, unless such persons to whom disclosure is to be made are identified in this or a supplemental Authorization. I understand that OAS may, from time to time, release confidential information to other offices and personnel of Eastern on a need-to-know basis in order to consider, process, and manage any requests for accommodations and that such disclosure is permitted under the law. I understand that these authorizations may be withdrawn at any time by me through a written, signed and dated request or by completing a new Authorization of Release and/or Obtain Information.

I permit AccessAbility Services to contact my current treating physician, psychiatrist, therapist, case manager, or provider to further discuss and/or obtain additional information regarding the nature of my medical condition, medical records, and history of treatment, if needed.

Informed Consent and Confidentiality

The Office of AccessAbility Services (OAS) 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 OAS and will be shared with students.  These guidelines incorporate relevant state and federal regulations.

  • No one will have immediate access to student files in OAS except appropriate staff of OAS.  Any information regarding a disability is considered confidential and will be shared only with others within the university who have a legitimate educational interest.
  • This information is protected by the Family Educational Rights and Privacy Act (FERPA)
  • Sensitive information in OAS student files will not be released except in accordance with federal and state laws.
  • A student’s file may be released pursuant to a court order or subpoena.
  • If a student wishes to have information about his/her disability shared with others outside the University, the student must provide written authorization to the OAS Director to release the information.  Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released.  The student should also understand that there may be occasions when the Director will share information regarding a student’s disability at his/her discretion if circumstances necessitate the sharing of information and the Director has determined that there is an appropriate legitimate educational interest involved.
  • A student has the right to review his/her own OAS file with reasonable notification.
Informed Consent Required