Public Accommodation Request

Self-Disclosure Form

If you need assistance in completing this form, please contact Disability and Access Resources.

Pennsylvania College of Technology provides appropriate accommodations to students with documented disabilities and/or diagnoses who elect to disclose their needs. Completing this form and submitting documentation will assist staff in understanding how to best support you in your courses, programs, and activities.

First Name

Last Name

Preferred Name

Student ID

Student Phone Number

Penn College Email

We will communicate important information with you via your Penn College email

Disability/Diagnosis Information

My diagnosis falls into the following category

To select multiple disabilities, please use the "select" dropdown menu again.

Please share additional information regarding your diagnosis if other was selected.

How does your diagnosis impact you in the academic, online learning, and/or campus community environment?

(testing, dining, housing, note taking, etc.)

What accommodations and/or services have you found helpful in your previous learning environment?

If applicable, list any side effects related to treatment and/or medication that may impact your learning experience.

Upload supporting document(s)

Please use this section of the form to upload documentation of your diagnosis. Documentation can also be provided using the contact information on our website.

Student Signature

Please type first and last name to indicate that the information on this form is accurate and complete.

Accommodated Placement Test Request

Please note that disability/diagnosis documentation is not required for your Accommodated Placement Test Request. Documentation will, however, be required to determine eligibility for accommodations and services once an enrolled student and will be reviewed upon submission.

Are you requesting accommodations for your Placement Test?

Public Accommodation Request

Self-Disclosure Form

Disability/Diagnosis Information

Accommodated Placement Test Request

Document Information