Appeal Form: Denial of Academic Accommodations
Section V: Release of Information
Please indicate below the documentation, files and forms that you would like released as part of your appeal process.
Documentation from High School or K-12 (Example: Individual Education Plan (IEP), Re-evaluation Report (RR), 504
Plan, Psychoeducational Evaluation or Neuropsychological Evaluation)
Documentation from previous college or university (Example: Accommodation Letter, College/University Verification
Form, Psychoeducational Evaluation or Neuropsychological Evaluation)
Medical Documentation (Example: Physician Letter, Verification Form, Audiology Report)
Psychological Documentation: (Example: Psychiatrist Letter, Verification Form, Psycho-educational Evaluation or
Accessibility Office Communications with the Student
Accessibility Office Forms
Other: (Please Specify)
Section VI: Submitting This Form
It is the responsibility of the student to submit the form to the Accessibility Office (TAO) at Bucks County Community
where the student is enrolled. The student will submit the form to the Director of the Accessibility Office
and is required to make an appointment to submit the form and discuss the appeal and the process. It is the
responsibility of the student to read and understand the Appeal Process and follow that process as provided on the
Section VII: Student Consent and Signature
Read and sign the following statement before your appeal can be considered:
1. I give my permission to the Bucks County Community College Accessib
ility Office to share a summary of any relevant
documentation of my disability with the Associate Provost in order to consider my appeal.
a. This is in addition to the requested documentation listed in Section V of this form.
2. This release will expire when my appeal is decided.
3. I understand that any false statements on my part may be sufficient for dismissal of my appeal.
I have read and understand the above information:
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