Public Accommodation Request

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Student Information

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Office of Disability ResourcesRequired

I acknowledge that I am the student requesting accommodations through the Office of Disability Resources.

If different from legal name

Please use your Purchase College issued ID number. Your ID number begins with P00... and can be located via your myHeliotrope account

Please use your Purchase College issued email address

Specific Accommodation Information

Choose all that apply. Please be as accurate as possible. Your answer will determine which ODR staff member you will be assigned to work with.

Please note: The Office of Disability Resources staff are mandated reporters, including in situations where a student expresses the intent of harm to self or others, and where a student discloses sexual harassment, sexual assault, gender-based harassment, stalking, and/or dating violence and domestic violence as outlined in Title IX. Students do not need to disclose any information related to a Title IX incident to request accommodations through ODR. 

Are you requesting academic accommodations?Required
Are you requesting housing accommodations?Required
Are you requesting dietary-related accommodation due to a disability/medical need?Required
How do you intend to submit your supporting documentation?Required
Upload supporting documentation

Students are not required to submit documentation at the time they submit this form. No student should delay submitting this form or meeting with ODR out of concern for not having appropriate documentation, though any documentation information students can share before or during the first meeting is helpful. The Office of Disability Resources' Documentation Guidelines webpage outlines different types of documentation that may be helpful. 

Student Acknowledgement Form

In order for the Office of Disability to process accommodation requests, students are asked to review and electronically sign the Student Acknowledgement Form below. Please note that when accommodation letters are distributed, specific information pertaining to diagnoses and disability-related symptoms will not be disclosed.

Release of InformationRequired

I authorize the Office of Disability Resources (ODR) staff, including Cornerstone Program staff, to exchange with/discuss with/release information about my accommodation request and disability-related needs and services to the following persons, as deemed helpful to me and in my best interests: 

  • Faculty
  • Advising
  • Purchase College Association
  • Office of Residential and Student Life
  • Counseling Center
  • Athletics Department
  • Administrators
  • Other School Officials
  • Legal Counsel

The Office of Disability Resources adheres to the confidentiality standards described in the College’s Policies Governing Student Records regarding the Federal Family Educational Rights and Privacy Act (FERPA).  Under this College policy, prior written consent by the student may be required before the ODR may release disability documentation and/or records to others depending on the circumstances.  

Please note:  This document will serve as written authorization under the College’s FERPA policy for the ODR to share information as it deems necessary in order to consider and implement your accommodations and services. 

You understand that this authorization will be deemed effective for the entire period you are studying at Purchase College and seek the assistance of the ODR, unless you otherwise affirmatively revoke your authorization in writing to the ODR. This authorization begins at the time this form is submitted and applies during times away from Purchase College including, but not limited to breaks between semesters, medical leaves, studying abroad, etc.  

You understand that notification of accommodations needs and services are shared via Purchase College e-mail. 

Confidentiality and Maintenance of Records
  • The Office of Disability Resources (ODR) is the College agent charged with the responsibility for collecting and maintaining disability documentation.  
  • Documentation provided to the ODR is confidential and only shared with others with the expressed written permission of the student. 
  • Consent of the student will be requested prior to releasing medical/psychological documentation to a third party. Confidentiality is not maintained in the case of child abuse, suicidal or homicidal intent, or legal action. 
  • All documents submitted to the ODR are maintained in a confidential paper file. The ODR also uses an electronic database to communicate with students and coordinate services. This system is hosted on a secure server and is developed using industry best practices. Access to paper and electronic information is limited to authorized ODR personnel only. 
  • Once a student no longer has contact with the ODR (e.g., graduates from Purchase College), paper files are securely stored for 7 years and then shredded. 

Your signature below indicates that you have read this information, that you understand the role of the above parties in implementing accommodation(s) and services based on your documented needs, and that you are hereby authorizing the Office of Disability Resources to share your disability-related information with the appropriate College officials for the purpose of addressing your accommodation needs and providing services. Your signature below also indicates that you understand that the Office of Disability Resources staff are mandated reporters. vYour signature below indicates that you have read this information, that you understand the role of the above parties in implementing accommodation(s) and services based on your documented needs, and that you are hereby authorizing the Office of Disability Resources to share your disability-related information with the appropriate College officials for the purpose of addressing your accommodation needs and providing services. Your signature below also indicates that you understand that the Office of Disability Resources staff are mandated reporters.