Fillable PLEASE READ CAREFULLY COMPLETE ONLY IF CLAIMING AN (Nassau Community College)

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PLEASE READ CAREFULLY COMPLETE ONLY IF CLAIMING AN (Nassau Community College)

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CENTER FOR STUDENTS WITH
DISABILITIES
Student Personnel Services
One Education Drive
Garden City, NY 11530-6793
Tel 516.572.7241
TTY 516.572.7617
Fax 516.572.9874
www.ncc.edu
COMPLETE ONLY IF CLAIMING AN ACCOMMODATION FOR A DISABILITY
PLEASE READ CAREFULLY
If you have a disability and believe you are entitled to any accommodations listed below AND you are certain that
you want to use them, YOU ARE REQUIRED TO:
• Complete this form.
• Provide complete documentation of the disability. See requirements below. If you
don’t have your documentation, obtain it from your school, licensed psychologist or physician.
• Email this form, along with the documentation to: CSDoffice@ncc.edu
Any items that are checked must be supported by documentation or they will not be provided.
THIS INCLUDES THE PLACEMENT TEST. Upon review, we will contact you regarding accommodations.
Disability: ___________________________________________________________________
I am requesting:
Reader (tape recorder or computer)
Scribe
Scantron exempt
___ Extended Time
___ Enlarged computer screen/printed copy
___ CCTV (closed circuit TV)
___ Sign Language Interpreter
___ Other _______________________
Student’s Name: __________________________________ NCC ID #: N00______________________
Entering Semester: Fall _____ Spring ____ Summer ____
(year) (year) (year)
Address: _______________________________________________________________________ _
(Number and Street) (Apt. #)
____________________________________________________________________________________________________________
(City) (State) (Zip Code)
Phone Number: Home: ______________________ Cell: _______________________________
Student Signature ___________________________________ Date__________________________
WHERE SUCCESS STARTS...AND CONTINUES 7/30/18
Nassau Community College is a unit of The State University of New York sponsored by Nassau County
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Disability Documentation Requirements
The following documentation is requested for the disability indicated. Please call the Center for
Students with Disabilities, (516) 572-7241 if you have any questions.
Learning Disability (LD) - Documentation must include Aptitude Test scores, including Subtest
scores, administered within the previous three years. The Wechsler Adult Intelligence Scale is the
preferred aptitude test. The Kaufman Brief Intelligence Test is not accepted. Documentation must also
include Achievement Test scores, administered within the previous three years. The Woodcock-
Johnson Test of Achievement is preferred. Woodcock-Johnson Cognitive scores are helpful, but not
required.
Other Health Impaired (OHI) - OHI covers a range of disabilities, including ADD, ADHD, Autism
Spectrum and more. The specific disability within OHI must be identified. Documentation must come
from the professional who diagnosed the disability, usually a licensed psychologist or medical doctor
and it must be diagnosed or reconfirmed within the previous three years. The IEP may not meet this
requirement.
Emotional Disability - The disability must be identified with the specific DSM 5 diagnosis made by a
licensed medical doctor, psychologist or other qualified health professional. The disability must be
diagnosed or reconfirmed within the previous three years.
Hearing Disability - Documentation must be provided by a licensed otolaryngologist, otologist or
audiologist and include an audiogram.
Visual Disability - Documentation must be provided by a licensed ophthalmologist, optometrist or
other appropriate medical specialist for visual impairment.
Physical Disability - Documentation must be provided by a licensed medical doctor or other qualified
health professional.
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PLEASE READ CAREFULLY COMPLETE ONLY IF CLAIMING AN (Nassau Community College)

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Completed 3 February 2021

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