Request for Accommodations

PHSC students may request accommodations by completing the Accommodations Request form below.

Nature of Primary Disability

If you have a disability, you may be eligible for Assistive Technology and/or Specialized Staff Assistance. To receive Assistive Technology and/or Specialized Staff Assistance, appropriate verification of the current disability must be on file with the PHSC Student Accessibility Services department. In addition, you are asked to provide more specific information by completing the remainder of this form. Appropriate documentation may come from individuals such as attending physicians, psychologists, psychiatrists, counselors, etc. from the Division of Blind Services, the Division of Vocational Rehabilitation, and the Veterans Administration.

Verification of disability must be emailed to sas@phsc.edu or may be submitted to the Student Accessibility Services department on PHSC’s West Campus in New Port Richey.

About You
Academic Information
Assistive Technology and Specialized Staff Assistance Request
As a student with a disability, are you in need of specific equipment or specialized staff assistance while continuing your education?
Please specify specific equipment or specialized staff assistance needed
Have you received academic accommodations in the past?
Certification and Authorization

The Assistive Technology and/or Specialized Staff Assistance services I requested is not available to me from any state or federal program responsible for such assistance, and if currently a client of another agency, I will inform the Student Accessibility Services department if my financial benefits for assistive technology/services have changed. I will contact other appropriate agency/agencies for possible sponsorship, and I will inform the Director or Assistant Coordinator of PHSC’s Student Accessibility Services department of the results of the contacts. I authorize PHSC to refer me to other agencies.

I give permission for the Director or Assistant Coordinator of Student Accessibility Services department, the Vice President, an Advisor, and/or Assistant Dean of Student Affairs to share with members of the administration, faculty, and/or advising staff any diagnostic and/or instructional information about me for the purpose of assisting me in my studies and coursework. I also give permission for the staff to release information to outside agencies upon my request.

This webform is adapted from college form ODS-1 (Rev. 10/19).