Student Disability Services Application

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.

*First Name:
*Last Name:
*Student ID:
*Pronouns:
*Date of Birth:

Local Address

*Address:
*City:
*State:
*Zip:

Contact Information

Disability Services will use your @live.eicc.edu school email address for correspondence.

*EICC Email:
*Secondary Email:
*Cellphone:
*Phone:
*Student Status (number of completed semesters in college):

Non-School Contact Information (if different from above)

*Address:
*City:
*State:
*Zip:
*Email:
*Phone:

*Which college will you be attending? Clinton Community College
Muscatine Community College
Scott Community College
ACCESS Program

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.

Initial the box to confirm that: 'I have read and fully understand the Disability Services in College statement.'

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.

ADHD ADHD
ADD

Anxiety Disorders Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Post-Traumatic Stress Disorder (PTSD)
Social Anxiety Disorder
Specific Phobias

Autism Spectrum Disorder ASD
Asperger’s
Pervasive Developmental Disorder NOS

Blindness, Low Vision Blindness
Low Vision

Chronic Health Physical Arthritis
Cancer
Cerebral Palsy
Chronic Migraines
Chronic Obstructive Pulmonary Disease (COPD)
Cystic Fibrosis
Diabetes
Epilepsy or Seizure Disorder
Fibromyalgia
General Chronic Health Issues
General Mobility
Long Covid
Multiple Sclerosis
Muscular Dystrophy
Orthopedic Impairment
Rheumatoid Arthritis

Deaf Deaf
Hard of Hearing

Learning Disability Auditory Processing Disorder
Dyscalculia
Dysgraphia
Dyslexia
Language Processing Disorder
Specific Learning Disability - Math
Specific Learning Disability - Reading
Specific Learning Disability - Writing
Non-Verbal Learning Disability
Visual Perceptual/Visual Motor Deficit

Mood Disorder Bipolar Disorder
Cyclothymia
Depression
Major Depressive Disorder
Persistent Depressive Disorder
Seasonal Affective Disorder (SAD)

Personality Psychotic Disorders Borderline Personality Disorder
Schizoaffective Disorder
Schizoid Personality Disorder
Schizophrenia

Temporary Disability Broken Bone
Other Temporary Condition

Traumatic Brain Injury Post-Concussion Syndrome
Traumatic Brain Injury
Other Disability or additional information you wish to share
Diagnosis: Describe your disability (or disabilities) in your own words
Describe difficulties/barriers in the classroom setting that are related to your disability
How does your condition impact you in evaluations such as tests, papers, oral reports, and group projects?
How does your condition impact you when doing out-of-class assignments in reading, writing, calculating, keyboarding, and library work?
How does your condition impact you when there are time constraints in the following areas: timed exams, deadlines, and class schedule?
Are there any other areas that your condition may impact your access to the educational experience? Please specify.
List accommodations you are seeking:
(Ex. extended time for exams, reduced distraction testing environment, read aloud software for exams, record lecture, audio or books in an alternative format, assistive technology, or sign language interpreters)
Have you received academic accommodations or services previously in high school or college? Please list those accommodations:

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

CCC: cccdisabilityresources@eicc.edu

MCC: mccdisabilityresources@eicc.edu

SCC: sccdisabilityresources@eicc.edu

ACCESS: Jen Aplington at japlington@eicc.edu

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, equity@eicc.edu 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 OCR.Chicago@ed.gov.