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Online Disability Self-Disclosure

Disability Self-Disclosure and Request for Access Accommodations Form

This form is for use by students to self-identify their status as a person in the protected class of disability as well as to request access services, if needed.

The office of Student Disability Services (SDS) facilitates services and accommodations for students with disabilities. Examples of covered conditions include: Attention Deficit/Hyperactivity Disorder (ADHD); autism spectrum disorders; chronic medical conditions (cystic fibrosis, diabetes); learning disabilities; mental health disabilities (bipolar disorder, depression, post-traumatic stress disorder); mobility disabilities (use of wheelchair or other assistive device); neurological disorders (traumatic brain injury, epilepsy, motor or tic disorders); orthopedic disabilities (bone or muscle disorders, connective tissue disorders); sensory disabilities (hearing, vision). Examples of accommodations include extended time for test-taking, accessible campus housing, transportation assistance, and textbooks in digital format.

If access accommodations are needed, this form gives you, the student, the opportunity to give SDS additional information about your disability, the impact of the condition, the accommodations that you will need to address the impact, and the accommodations you have used in the past.

Please complete this form and submit it along with your disability documentation if you are requesting accommodations. The access accommodation request process is finished when all of the following steps have been completed:

1. Submission of this "Disability Self-Disclosure and Request for Access Accommodations" form.

2. Submission of current and comprehensive disability documentation that meets SDS guidelines. (Documentation guidelines are available at http://sds.cornell.edu.) Documentation can be securely uploaded online with or after submission of this form, faxed to 607 255-1562, or mailed or delivered to Student Disability Services, Cornell University, 420 CCC, Ithaca, NY 14853-6601 (please note: after August 1 our address will be changing to: Student Disability Services, Cornell Health Building 5th Floor, 110 Ho Plaza, Ithaca, NY 14853).

3. You have met with a SDS staff person for an initial assessment interview after the SDS staff person has reviewed your disability documentation.

Accessible Housing Requests
  • For fall semester admission, first-year student requests for accessible housing and supporting documentation should be submitted to SDS by May 15; transfer and graduate student requests should be made as soon after admission is possible.
  • For spring semester admission, all accessible housing requests should be made by December 1.
  • For continuing student academic-year housing, requests, including a meeting with an SDS counselor, should be submitted by February 5.
  • Students who are approved for accessible housing after the room assignment period will be placed on a wait list.

While requests for disability services may be made at any time, we strongly encourage you to submit this request with your disability documentation as early as possible. Doing so will facilitate the timely provision of accommodations approved by SDS. SDS staff may consult with subject matter experts in health fields regarding accommodation requests.

Information provided to SDS is confidential. Note: Information submitted on the Health History Form to Cornell Health is not shared with SDS.

Need more information? Contact Student Disability Services, Cornell University (telephone: 607 254-4545; fax: 607 255-1562; Deaf/HOH: via 711 Relay; e-mail: sds_cu@cornell.edu); website: http://sds.cornell.edu.

PLEASE NOTE: Responses are required for all questions. Please use "Not Applicable" if the question does not apply to your situation.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  3. Hint: Enter your 7 digit Cornell ID Number
Contact Information
  1. Hint: Enter 10-digit number only (i.e. enter 5417377000 for 541 737 7000).
  2. Hint: Enter 10-digit number only (i.e. enter 5417377000 for 541 737 7000).
Questions
  1. What is your Cornell status?
  2. What is your Cornell college or school?
  3. What is your degree program?
  4. What campus are you on?
  5. Into which of the following categories does your disability (or disabilities) fall? You may select more than one:
  6. Are you requesting disability services? Please select one of the following:
  7. In your own words, please describe your disability and its impact on your daily life.
  8. Does your disability affect you in an academic setting? If so, please explain.
  9. List the accommodations you are requesting in an academic setting (e.g., test-taking accommodations, books in alternative format).
  10. Have you requested on campus housing? If so, please specify building and room number:
  11. Does your condition affect you in a residential setting (e.g., residence halls, dining halls)? If so, please explain
  12. List the disability-related accommodations you are requesting in a university-owned residential setting (e.g., strobe alarms, wheelchair accessible housing), if applicable.
  13. Does your condition affect your transportation needs (e.g., bus pass, accessible parking, paratransit service)? If so, please explain
  14. Describe auxiliary aids, assistive technology and/or services that you anticipate using while attending Cornell (e.g., service dog, personal assistant, FM system, wheelchair).
  15. List the secondary school(s) you attended and any disability accommodations and/or services you used in high school.
  16. List any colleges attended and disability accommodations and/or services used there.
  17. List any national standardized exams (e.g., SAT, ACT, GRE, LSAT, GMAT) you have taken and any accommodations used for each.
  18. Please review SDS documentation guidelines at www.sds.cornell.edu and submit appropriate documentation for your disability. In addition, please submit copies of IEP/504 plans and/or accommodation letters from national standardized exams. (Online submission using this site is a secure method of submitting documentation.) Please note that files must be 3MB or less in size.
  19. I authorize SDS to discuss my documentation with the clinician who authored the documentation, or a similarly-qualified Cornell clinical staff person or consultant, if additional information or clarification is required.
  20. By submitting this form, I certify that the information provided on this form is accurate. I understand that to be eligible for access accommodations at Cornell University I must (1) submit this completed form, (2) submit disability documentation that substantiates the requested accommodations, and (3) participate in an initial individual assessment with a Student Disability Services staff person.
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