Fillable Appeal Form Denial of Academic Accommodations Section I: (Bucks County Community College)

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Appeal Form Denial of Academic Accommodations Section I: (Bucks County Community College)

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The Appeal Form Denial of Academic Accommodations Section I: (Bucks County Community College) form is 3 pages long and contains:

  • 1 signature
  • 15 check-boxes
  • 66 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bucks County Community College

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Appeal Form
Denial of Academic Accommodations
Bucks County Community College’s Accessibility Office (TAO) has established the Appeal Form for Denial of Academic
Accommodations to aid in the appeal process in the event that a request academic accommodation is denied by and
Instructor or TAO. This form is required for the appeal process and must be completed in full to be accepted to begin the
appeal process.
The student is required to complete the form. If aid is required in completing the form, a statement
must be provided of who has provided aid and why aid was required in completing the form.
Section I: Student Information (Please type information or print legibly)
Student Name:
Last
First
Middle
Student ID:
Date of Birth:
Cell Phone:
Home Phone:
Bucks Email:
Home Email:
Permanent Street
Address:
City:
State:
(If different from Permanent Street Address)
Local Street
Address:
City:
State:
Section II: Identify the reason for your appeal (Check One)
Accommodation not approved by the Accessibility Office
Accommodation denied by Instructor
Section III: Specific Course and Semester Information (Please type information or print legibly)
Academic Year:
Fall
Winter
Spring
Summer I
Summer II
Summer III
Courses for indicated semester: Please include course and section numbers (Example: MATH 095-N10)
#1
#6
#2
#7
#3
#8
#4
#9
#5
#10
Revised March 2020
Appeal Form: Denial of Academic Accommodations
Section IV: Appeal Narrative (Please type information or print legibly)
Please describe why you are filing this appeal. It is important for the student to be specific regarding the accommodation,
the course, an
d Instructor (if applicable). If you need more space, please continue writing on a separate sheet and
attached to this form when it is submitted.
It is important for the student to state why they believe the appeal
should be approved.
2
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.
Inattention:
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
Neuropsychological Evaluation)
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
College
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
TAO website.
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:
Student Signature
Date
3
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Appeal Form Denial of Academic Accommodations Section I: (Bucks County Community College)

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Completed 3 October 2020

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