# Delta College Request for Records/Release of Information

The purpose of this request for information is to determine my eligibility for reasonable and appropriate accommodations at Delta College.

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[Open original PDF →](https://www.delta.edu/services-support/_documents/records-release-of-Information.pdf)

## Document text

Office of Disability Resources D-101

E-mail: disabilityresources@delta.edu

## Delta College Request for Records/Release of Information

The purpose of this request for information is to determine my eligibility for reasonable and appropriate accommodations at Delta College.

I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      Birth date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

hereby authorize Delta College Disability Resources to \_\_\_\_\_ release / exchange information with:

- [ ] \_\_\_\_\_ request information from:

Name / Agency \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   State: \_\_\_\_\_\_\_\_   Zip: \_\_\_\_\_\_\_

Phone #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Specific type of information requested:

- [ ]  All Information

- [ ]  Accommodations Using / Requested

- [ ]  Diagnosis of Disability / Condition

- [ ]  Functional Limitations

- [ ]  Medication / Aids /  Recommendations

- [ ]  IEP and Psycho-Educational Evaluation including aptitude and achievement scores

- [ ] 

Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This document has been explained to me and I understand the contents. I understand that this consent may be revoked by me, in writing, at any time. It is valid only for the time reasonably necessary to accomplish its purpose.

I further understand that all records, and subsequent communications, obtained by Delta College on my behalf, will be treated confidentially, and maintained separately from academic records.

By signing this form I am agreeing to the information being released to Delta College for use in helping me plan my educational program, and secure appropriate resources and reasonable accommodations. Additionally I grant permission for communication between Evaluator and Delta College regarding information related to diagnostic assessments, evaluations, and for recommendations.

Student's Signature

: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

College Representative: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The professional findings and proper documentation must, at the minimum, be provided on formal letterhead, in letter form, and signed by the professional, who is qualified to determine specific diagnosis.

I understand that any copying/mailing costs associated with obtaining necessary third-party documentation are my responsibility, and will not be paid by Delta College or its representatives.

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<small>Source: [https://www.delta.edu/services-support/_documents/records-release-of-Information.pdf](https://www.delta.edu/services-support/_documents/records-release-of-Information.pdf)</small>