ACCESS Center Intake Form

Student Information

New to ACCESS Center? Welcome!

In order to request accommodations from the City Colleges of Chicago you are required to complete both the Student Intake Form and upload your documentation using the link below.

When both your intake and documentation have been approved you will receive an email to your CCC student email with instructions on how to schedule an intake appointment with your home campus ACCESS Center (AC) Director.

Do you have documentation of your disability?

First Name

Last Name

Middle Name

Preferred First Name

This is the name AC will use for correspondence and your letter of Accommodation.

CCC Student ID

CCC Student Email

Please use your City Colleges of Chicago issued email address

Student Phone Number

Is this a temporary disability or condition?

Is this a pregnacy related accommodation request?

Specific Accommodation Information

My diagnosed disability(ies) best fall into the following category(ies)

If you selected an option that includes "other" above, please list the diagnosis here.

What is your primary disability, which one impacts you most in an academic setting?

How does your disability affect you academically?

What, if any, accommodations have you received in the past?

Do you use any assistive devices or technology?

(example: audiobooks, recording device, etc.)

Do you need emergency evacuation assistance?

What additional information would you like AC to know about your request?

(example: fatigue/tiredness, need to carry food/water, etc.)

Documentation

Upload supporting document(s)

Documentation may include:

IEP/504 plan, Psychological Evaluation or Re-Evaluation, or a write-up from your care provider.
Disability diagnosis from a licensed clinical professional familiar with your history, e.g., a therapist, physician, social worker, or school psychologist.

For further information about eligible documentation please use the link below: https://colleges.ccc.edu/accessibility/

ACCESS Center Intake Form

Student Information

Specific Accommodation Information

Documentation

Document Information