Important Information: Coronavirus (COVID-19)

All academic instruction will continue online through the end of the spring 2020 terms. Residence halls, and faculty and staff offices are closed. All events and activities are cancelled until further notice. Read more here for up-to-date resources and communications. For questions or to provide information that might be useful to the College, please email

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DIRECTIONS AND DISCLOSURES: Please answer the questions on this form to the best of your ability. Your answers are valuable and they help us understand how best to assist and accommodate you. Your information will be treated confidentially and maintained securely in our office. We will release information about you only with your written permission to do so.

General Information
Education Level
Disability Information


List any current treatments for your disability (medication, counseling, physical therapy, etc.):

Please describe your disability(ies):

Accommodation Information
Please understand that requesting an accommodation does NOT guarantee that you will receive it.

Please describe the accommodations that you are interested in seeking:

In your own words, please describe the nature of your condition and how it may impact your Mercy experience:


I understand and agree to the following:

  1. The responsibility for obtaining reasonable accommodations in the classroom is mine; if I need assistance, I will contact the Office of ACCESSibility (ACCESS) via phone or email: (914) 674-7523 or


  1. The reasonable accommodations that are available to me are only those agreed upon during the registration process. If I feel that I need to adjust my accommodations, I will contact ACCESS to review. I understand I may need to provide additional or updated documentation during the review process.


  1. If I require extended time or separate location for an examination I will provide my professor with the Proctor Request Form.  The completed Proctor Request Form must be completed by my instructor and delivered to the Office of ACCESSibility at least 1 week before the exam date. I understand that if I do not provide the completed form to ACCESS at least 1 week before the test, I will not be guaranteed a proctor.  All of the appropriate campus contacts for setting up a proctor are listed on the Proctor Request Form.


  1. At the start of each semester, I will contact ACCESS to activate my accommodations.  This activation will provide you with a new and current Accommodation Memorandum.  I will deliver the Accommodation Memorandum to the instructors and discuss a plan with them. I will have each instructor sign the form and then I will return the form to ACCESS. 


  1. If the reasonable accommodations are not being met as stated in the Accommodations Memorandum, I will contact ACCESS as soon as possible. I will not wait until the end of the semester as the ACCESS will be unable to change the outcome without prior notice of the situation.


  1. Stay connected with ACCESS staff.  Communicate with the staff and tell them about any problems that arise.  It is a joint process to find solutions to problems.  Staff can brainstorm ideas that may solve a potential problem, or prevent a future one.


  1. Return borrowed equipment at the end of the semester.  All borrowed equipment must be returned in the condition it was received. 

Extra time for testing in a supervised, separate location outside the classroom is a reasonable accommodation to help you have equal access in college.  You, as well as our other students, rely heavily on this service.


In the Office of ACCESSibility, we put our trust in you and expect you to conduct yourself with integrity.  We WILL NOT tolerate cheating of any kind.  Professors expect that we enforce the No Cheating rule and we do not want our services to be put in jeopardy.  Your dishonesty will not only affect you, but will affect others using our services.



If you abuse this accommodation by cheating your exam will be taken away from you.  Your professor will be notified and will follow Mercy College’s cheating policy as per the college handbook.


Mercy College’s Cheating Policy as stated in the handbook:

“Cheating and plagiarism are contrary to the purpose of any educational institution and will be dealt with severely. An instructor who determines that a student has cheated on a test or assignment will at a minimum give a zero for that item and may give a failing grade for the course. Normally, the matter is handled between the instructor and the student, but the department chairperson and other school officials may be consulted by either party to ensure fairness.”


“Both cheating and plagiarism are grounds for dismissal from the College.”


Disclosure of Disability Agreement Form

I authorize the Office of ACCESSibility (ACCESS) to share my disability diagnosis and any academic learning strategies, specific to my disability, with the following support services:

I am authorizing ACCESS to only do this if the support service is seeking assistance in providing me with the best educational consultation available. I understand that this information will be shared with respect and dignity and will remain confidential between ACCESS and the support service. If I choose to terminate this agreement, I can do so at any time. If I have any questions, I understand that I can contact ACCESS at (914) 674-7523 or via email at

Limited Release of Information
I hereby give permission for the Office of ACCESSibility Staff to provide limited information regarding my status as a student with a disability to other pertinent parties of Mercy College on an as needed basis. No specific release of medical/educational records will be released without my expressed written permission. This release will remain in effect for the duration of my educational career at Mercy College, unless I choose to revoke it and discontinue my connection with the Office of ACCESSibility.