Student Disability Services Intake

Dear Student:

Thank you for your interest in the services offered by Disability Services through your EICC campus. It is important that you complete and return this application, along with documentation of your disability, as soon as you are aware of a disability-related need for services. This will allow the Disability Services Provider (DSP) to work with you in planning effective academic accommodations at EICC.

Please note that your request for services will not be reviewed until your application and documentation have been received. Accommodations may take time to implement and may not be available immediately.

Information provided to the DSP is confidential. Disability service providers will discuss your accommodations with faculty and staff only on a need-to-know basis.

Asterisk (*) indicates a response is required.

Local Address

Contact Information

Disability Services will use your school email address for correspondence.

Non-School Contact Information (if different from above)

Disabilities Services in College Statement

Eastern Iowa Community Colleges are committed to providing reasonable accommodations to qualified students with disabilities. These accommodations are provided to assist students with disabilities in accessing the programs, services, and activities at EICC. Working in partnership with the student, the Disability Service Provider will develop an individual plan (letter of accommodation or LOA) for services that will include accommodations in testing and instruction. Students with disabilities must submit documentation that verifies the presence of a disability that creates a barrier to access of the program, services, or activities of the college. The student must request services and obtain an updated LOA each semester of attendance. Please note that accommodations do not lower program requirements and standards.

Disability Information

In this section, please tell us about your disability.

For what diagnosed disability (or disabilities) are you seeking accommodations? Please check all the boxes that apply.

Send documentation of your disability to the DSP on your home campus:




    ACCESS: Jen Aplington at

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339