Center for Access and Accommodative Services
Triton College
2000 Fifth Ave., River Grove, IL 60171
Room A-125
Phone: (708) 456-0300, Ext. 3853, 3854 or 3917 Fax: (708) 456-0991
TTY: (708) 583-3182
REQUEST FOR ACCOMMODATIONS
CONFIDENTIAL DATA FORM
Today’s date________________ Semester requesting services for _______________________________
Name _____________________________________________________________________________________
(Last) (First) (Initial)
Address ___________________________________________________________________________________
City _______________________________ State __________________ Zip code _____________________
Home phone ( )________________________ Cell phone ( )________________________
____________________________________________
____________________________________________ _____________________________________________
Birth date ____________________________ Age _________
Emergency contact person ___________________________ Relationship __________________________
Phone number ____________________________________________________________________________
Name of person who referred you to this center ______________________________________________
The following information is requested so Triton College may demonstrate compliance with
federal and state requirements. Ethnic origin (check one):
Asian/Pacific Islander Hispanic
American Indian/Alaskan Native White/Non-Hispanic
African American/Non-Hispanic Other
Are you a military veteran? Yes No
CAAS
Center for Access and Accommodative Services
Personal Email Address
Triton College Email Address Gender
F M Not Specified Transgender
Semester Year
Educational History
Your level of education:
Not a high school graduate
High school graduate Year_________ School __________________________
GED Year_________ School __________________________
College Year_________ School __________________________
Home schooled Year_________
H.S. Transition Program ___________________ Year_________ School __________________________
Did you receive accommodative services in high school?
Yes No
Did you receive any of the following: (Check all that apply.)
Resource room assistance Collaborative classroom
Social work services Self-contained classes ______________________
ELL or ESL classes
Mainstream classes, list classes________________________________ __________________________
Did you receive accommodative services in college? Yes No
College name ___________________________________________________________________________
What accommodations did you receive at the last school you attended:
Accommodative testing / Describe: _______________________________________________________
Note taker or copies of class notes
Sign language interpreters
Enlarged text materials/CCTV
Alternate text materials / Describe:_______________________________________________________
Reader services / Describe:_______________________________________________________________
Use of assistive technology / Describe:_____________________________________________________
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Learning Difference, Medical Condition or Disability
Have you been diagnosed with a medical condition or disability? Yes No
Diagnosed date_____________________________________________________________________________
Date of last psychological testing for a learning disability ___________________________________
The medical condition(s) or disability you have been diagnosed with:
Post-Traumatic Stress Disorder
Learning disability
Intellectual disability
ADHD/ADD
Autism
Asperger’s Spectrum
Acquired brain injury / Date: ______________
Deaf/hard of hearing ___________________________________________________________________
Visual Impairment / Describe:____________________________________________________________
Mobility Impairment / Describe:__________________________________________________________
Temporary Injury/Illness / Describe:_______________________________________________________
Mental health / Describe:________________________________________________________________
Physical disability / Describe: _____________________________________________________________
Medical condition / Describe: ___________________________________________________________________
Transplant, implant, shunt / Describe: ____________________________________________________
Other / Describe:________________________________________________________________________
Do you use any of the following:
Crutches
Cane
Walker
Manual wheelchair
Electric wheelchair
Prosthesis / Describe: _______________________________________________________________________
Other / Describe: _______________________________________________________________________
Do you have an active case with the following:
Department of Human Services/Office of Rehabilitation Services
Veteran’s Administration
Employment Training Services
Physical/Occupational Therapy
Transition from high school to college/work program
Personal counseling with a therapist or psychologist
Case manager or counselors name ________________________________ Phone __________________
Date of last meeting ____________________________________________________________________
How often do you meet with this professional? ____________________________________________
Agency name ___________________________________________________________________________
Address _________________________________________________________________________________
Services you received _____________________________________________________________________
- 3 -
Shunt
Cochlear Implant
Pacemaker
Vagus Nerve Stimulator (VNS) Devices
Medications you are taking Reason Side effects you experience
- 4 -
Explain how your medical condition/disability affects you in your daily life and academics.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List adapted equipment and/or software you have used in the past, i.e., screen reading
software (JAWS), reading programs (Kurzweil).
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you currently undergoing treatment for any additional health-related concerns?
Yes No
Do you currently wear a medical ID or carry medical information with you daily?
Yes No
Are you interested in sharing your medical information with the campus nurse?
Yes No
Attending Triton College
Your academic goal is to:
Noncredit classes for self-enrichment
Complete certificate from The School of Continuing Education
_____________________________________________________________
GED classes
Participate in the Project Achieve Employment Skills Program _____________________________
Complete a college certificate ___________________________________________
Complete a degree at Triton, then apply that to work ____________________________________
Complete a degree at Triton to transfer to a university ___________________________________
Take general education classes to transfer to a university
If you plan to complete a certificate or degree, what will your academic major be?
_________________________________________________________________________________________
Do you plan to attend Triton College as a full- or part-time student? ____________________________
Have you applied for financial aid? ________ Application date _________________________________
Have you received a notification of your financial aid award? __________________________________
Do you plan on participating in any campus clubs or sports teams? ______________________________
List _________________________________________________________________________________________
_________________________________________________________________________________________
List the type of classes that are easier for you.
_________________________________________________________________________________________
_________________________________________________________________________________________
List the type of classes that are more difficult for you.
_________________________________________________________________________________________
_________________________________________________________________________________________
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ESL classes
Part Time
Full Time
No
No
No
Check the accommodations you have found to be helpful and wish to use at Triton College.
Testing accommodations
Extra time on exams
Test read aloud by Kurzweil Reading Software
Low distraction room for testing
Enlarged print
Use of computer for writing
Note taker
Audio Record Lectures
Sign language interpreting services
Assistance crossing Fifth Avenue
Alternate text materials / Describe: _________________________
Use of assistive technology
Kurzweil Reading software
CCTV
Zoomtext
Are you able to accurately fill out the bubble of a scantron sheets? Yes No
Other / Describe: ____________________________________________________________________
During an evacuation of a building, would you like to have first responders check to see if you
have exited? Yes No
Privacy Act
This request for information is necessary in order to properly conduct the program and account
for the activities of the CAAS. Failure to supply all requested information may result in a delay
of access and/or accommodative services. All records are confidential and retained in secured
files. The information in this application is true and complete to the best of my knowledge.
________________________ _______________________ __________________
Print name Signature Date
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Student Contract
Complete all recommended assessments offered by the college and CAAS.
Submit all necessary documentation of my medical condition and/or disability to CAAS.
Attend a training to activate the services I am requesting to aid me in successfully completing
each class I register for.
Attend a training session on all adaptive equipment I will need.
Comply with the college rules of conduct.
Inform CAAS of all class schedule changes and changes of academic goals.
Establish accommodations by presenting the CAAS card to instructors of the classes where
services are needed.
Renew CAAS accommodations each semester in the CAAS office at the time of registration.
Consider participating in one or more CAAS workshops the first semester receiving services
from CAAS and each semester I do not obtain a 2.0 GPA.
Regularly attend all classes and lab sessions.
Consider making use of faculty office hours and regularly attend tutoring sessions and
supplemental labs to enhance your understanding of class materials.
I agree to abide by the above commitment and understand that violation of any conditions of
this agreement as stated in this form will make me subject to suspension from CAAS services
and/or other action at the discretion of the dean of Students and/or CAAS director.
________________________________________ ____________________________ _______________
Print name Signature Date
- 7 -
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STUDENT CODE OF CONDUCT
GENERAL REGULATIONS
College regulations apply to a student when on college property, attending a class, or when
representing the college at college sponsored events both on and off campus. The College
applies disciplinary sanctions for violation of these regulations. Should an act violate both college
regulations and public law, the student is subject to dual jurisdiction. Students will also be held
responsible for actions of their guests. Non-student visitors to the campus are expected to
comply with college regulations.
ACADEMIC DISHONESTY Written or other work a student submits in a course must be the
product of his/her own efforts. Plagiarism, cheating or other forms of academic dishonesty are
prohibited.
FALSE INFORMATION A student shall not furnish false or misleading information to college
officials.
BEHAVIORAL MISCONDUCT A student shall take no action which disrupts or tends to disrupt
the peace or which endangers or tends to endanger the safety, health or life of any person.
PROPERTY DAMAGE A student shall take no action which damages or tends to damage public
or private property not his/her own without the consent of the owner or person legally
responsible.
THEFT A student shall not take without authorization property for his/her own without the
consent of the owner or person legally responsible.
UNAUTHORIZED ENTRY Forcible or unauthorized entry onto any property or into any building
structure, utility or room on the premises is prohibited.
ALCOHOL AND DRUGS A student shall not possess alcohol, i.e., beer or liquor, except in
conformance with college policy. A student shall not manufacture, use, possess, sell, deliver or
distribute any illegal or controlled drugs or substance except under the direction of a licensed
physician.
WEAPONS/FIREARMS A student shall not possess or use firearms, explosive devices or any other
device classified as a weapon by the state of Illinois. Instruments used to simulate such weapons
in acts which endanger or tend to endanger any person shall be considered weapons.
CLASSROOM DISTURBANCE – Classroom disturbances which interfere with the educational process
are prohibited.
SMOKING Smoking of any sort is prohibited on Triton’s campus.
I understand and agree to abide by the Student Code of Conduct.
________________________________________ ____________________________ _______________
Print Name Signature Date
WE ARE TRITON.
2000 Fifth Ave., River Grove, IL 60171
(708) 456-0300
Triton College is an Equal Opportunity/Affirmative Action institution.
triton.edu | #WeRTriton
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