Disability Services Release of Information Form | Penn State World Campus Chaiken Center for Student Success

Student Disability Services (SDS) is committed to ensuring that student information is maintained confidentially as required or permitted by law. Any information collected is used for the benefit of the student. This information may include psycho-educational testing, grades, biographical history, disability information, and case notes.

For more information regarding confidentiality and release of information, please visit the Penn State Educational Equity page.

If you are unable to access this form, please contact your disability specialist.

First Name

Last Name

PSU ID Number

Penn State Email Address

Who is your disability services specialist?

Check the box with each of the following statements to indicate your acknowledgement. By submitting this form, you are giving permission to the Student Disability Services staff at Penn State to:

1. Request, receive, and discuss documentation for the purpose of determining program eligibility and planning appropriate academic adjustments, auxiliary aids, and services

3. Request, receive, and discuss applicable information with outside agencies providing services and supportive assistance (e.g., Office of Vocational Rehabilitation, Bureau of Blindness and Visual Services, and local services)

4. Exchange applicable information with the Disability Services Coordinator(s) at other Penn State locations for the purposes of seeking academic adjustments, auxiliary aids, and/or services

5. Request, receive, and discuss information with psychological services at Penn State’s Center for Counseling and Psychological Services (CAPS), the CEDAR Clinic, and the Penn State Psychological Clinic for the purpose of seeking academic adjustment, auxiliary aids, supportive assistance, and/or services

6. Exchange applicable information with another party: (Please list any other individual with whom information about your disability services can be shared, if applicable. This may be a friend, partner, parent, doctor, or another party. You can leave this section blank if you have no additional parties to add.)

Name of person with whom my information may be shared:

Relationship of party listed:

7. Utilize the most effective mode of communication (written correspondence, telephone, fax, and/or electronic mail) with the above-mentioned parties (1–6)

All information obtained will be maintained and used in accordance with the confidentiality requirements of FERPA (Family Educational Rights and Privacy Act). This release of information will expire in one year unless you choose to revoke sooner by written notice.

By checking this box, I give permission to the Student Disability Services staff at Penn State to share information about my disability services as indicated in this form.

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