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Request for Services and Documentation Review

Please note that your request for services will not be reviewed until a completed request form and documentation are received by the DSS office. Information provided to DSS is confidential. Documentation and evaluation information will not be released without the signed consent of the student or under compulsion of legal process. The DSS director or her designee will verify that your documentation is on file and will discuss your accommodations with only those faculty or staff with a need to know. Documentation information is not part of your academic transcript.

Release of Disability Related Information

I understand that in order for the DSS office to verify my disability, as well as the functional manifestations of my disability for which academic adjustments, auxiliary aids and/or other accommodative services may be required, DSS must obtain pertinent student evaluations, psychological reports, transcripts, and medical reports. I understand that to obtain these reports this form must be signed and on file in the DSS office.

I understand that no one other than DSS personnel has immediate access to my DSS files, and that any information regarding my disability which is gained from these files shall be considered confidential and will only be shared with others within the institution on a need-to-know basis. I further understand that my reports will not be released by DSS except in accordance with federal and state laws.

Therefore, for the purposes noted above and in accordance with the conditions specified, I hereby authorize release of information from my reports to authorized personnel at Midwestern State University and its DSS office.

Midwestern State University is not obligated to honor disability accommodations from previous institutions.

Academic requirements that are essential to the program of instruction being pursued by the student or to any directly related licensing or certification requirement will not be modified, substituted or waived.










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