Application for Accommodations
To request academic accommodations with the Northeast Iowa Community College (NICC) Office of Disability Services complete the application below.

The Office of Disability Services complies with the Family Educational Rights and Privacy Act of 1974 (FERPA) and NICC record retention policy in maintaining student records.

Information related to a student’s disability will only be released to a to an authorized NICC faculty and/or staff member upon a student’s written consent, and on an educational need-to-know basis.



First Name *
Your answer
Middle Name or Initial
Your answer
Last Name *
Your answer
What is your email address? NICC email address preferred. *
Your answer
Student ID Number
Your answer
Campus Location *
Date of Birth *
MM
/
DD
/
YYYY
Primary Phone Number *
Your answer
Secondary Phone Number
Your answer
Local Street Address *
Your answer
City/Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Permanent Address (if different than local address)
Your answer
Start Term *
Expected Graduation Term
Program of Study *
What is the most recent school you attended? What was your last date of attendance? Please include location.
Your answer
Did you receive accommodations from your previous school(s)?
If you are receiving services from Vocational Rehabilitation, please provide the name of your counselor and their contact information.
Your answer
In order to serve you best, please provide documentation prepared by a qualified professional. What type of documentation can you provide?
You may email, fax or hand deliver your documentation to the Disability Services Coordinator. Our contact information is at the bottom of this form.
What is the nature of your disability. Please choose all that apply to you. *
Required
In your own words, please describe your disability(ies) and how it affects your learning and testing. *
Your answer
If applicable, please list adaptive/computer technologies that you will be requesting or using.
Your answer
Please list any additional academic accommodations and services you are requesting.
Your answer
Have you applied for admission to the College? This application is not an application for admission, it is only for accommodations. *
I understand that in order to finalize my eligibility for disability services/accommodations, I am responsible for submitting documentation of my disability(ies) prior to meeting with the Disability Services Coordinator for my pre-service interview (see contact information below). I also understand that the application for Disability Services is independent from my application for admission. Mark YES for electronic signature. *
Disability Services Coordinators
Anna Stamat
Title: Disability Services Coordinator
Location: Calmar Campus
Student Center, Room 123
Email: stamata@nicc.edu
Phone: 563.562.3263, ext. 258
FAX: 563.562.4353


Adam Green
Title: Disability Services Coordinator
Location: Peosta Campus
Main Building, Room 220A
Email: greenad@nicc.edu
Phone: 563.556.5110 ext. 280
FAX: 563.557.0352


It is the policy of Northeast Iowa Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by federal and state civil rights regulations. If you have questions, concerns or to read the full policy https://www.nicc.edu/aboutnicc/nondiscriminationpolicy/.
Submit
Never submit passwords through Google Forms.
This form was created inside of Northeast Iowa Community College. Report Abuse