Office of Accessibility Services Initial Intake Form

Alvernia University

Office of Accessibility Services

Alvernia University is committed to providing equal access to educational opportunities, services and activities for students with disabilities.

The Office of Accessibility Services (OAS) engages in an interactive process with each student who self-discloses a documented disability to determine eligibility for reasonable and appropriate accommodations, as defined under federal law.

To request accommodations, please complete the form below. A member of the OAS team will review your request, documentation, and follow up with you via email about next steps. Please allow up to 2 weeks for processing.

If you currently have or have had accommodations established at Alvernia and need to request additional accommodations, please log into your Accommodate account and submit a supplemental application.

Student Information

First Name

Preferred First Name

Last Name

Student ID

Please include the P000 before the 6-digit ID number. Incorrect submission may delay processing.
(Example: P000123456)

Alvernia email address

Please use the email address that is First.Last@alvernia.edu. Incorrect submission may delay processing.
(Example: john.smith@alvernia.edu)

Student Cell Phone Number

Housing Status

Primary Campus

Accommodation & Diagnosis History

Is this request for a new diagnosis, or have you used accommodations in the past?

If you used accommodations previously, please list what worked best for you.

(e.g., extra time on tests, quiet testing room, specific software)

Specific Accommodation Information

Diagnosis/Condition(s)

Please indicate primary diagnosis/condition, if applicable.

Please describe your disability, chronic illness, or condition.

How does this condition impact your functioning as a student?

(e.g., in the classroom, taking exams, studying, meeting deadlines)

How does this condition impact your campus, housing or residential life? (If applicable)

What specific accommodations are you requesting at Alvernia University?

(e.g., housing adjustments, academic adjustments, assistive technology)

Documentation Upload

Supporting Documentation

Please upload documentation from a qualified professional supporting your request. Ideally, documentation should follow our guidelines posted on our website. Should you not have documentation to support your request, please reach out to Liz Peck, Director of Accessibility Services at accessibility.services@alvernia.edu.

Certification, Acknowledgement & Signature

Terms and Conditions

■ I certify that all statements in this request are complete, accurate, and true to the best of my knowledge.

■ I understand that all submitted documents will be securely retained by Alvernia University for the duration required by law and cannot be returned to me.

■ I understand that all submitted documents will not be returned to me, now or in the future.

■ I understand that the university may request additional documentation from appropriate professionals if needed to verify my condition or establish reasonable accommodations.

Digital Signature