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Temporary Medical Conditions Form

  • General Information

    You should complete this form before you meet for accommodations with Disability Services.
  • MM slash DD slash YYYY

  • Medical Information

  • Please provide medical documentation to support the above description of your temporary medical condition.

    Mail Documents:
    ATTN: Lisa Vance
    500 College Drive
    Mason City, IA 50401
    Email: lisa.vance@niacc.edu

  • Accommodation Request

  • Acknowledgement of Understanding

    I understand that completing this form is only the initial step in the temporary accommodation process. Once I have provided this intake and documentation about my medical condition, I will need to meet with the Director of Disability Services to request accommodations and provide notification to instructors. As an alternative, if you are not able to meet on campus, you can complete the Online Request for Accommodations Form.

    I also understand that I am my own advocate. It is my responsibility to request accommodations and to notify instructors of my need for accommodations. It is also my responsibility to report any concerns I may have regarding accommodations to the Disability Services Office.

    I affirm that the information contained in this form is true and accurate to the best of my knowledge. If any information changes, I will notify the Disability Services Office immediately.

  • Understanding Disability Services in College

    North Iowa Area Community College (NIACC) is committed to providing reasonable accommodations to qualified students with temporary medical conditions. These accommodations are provided to assist students in accessing education at NIACC. Working in partnership with the student, the Disability Services Director will develop an individual plan for services. Please note that program requirements will not be altered and standards will not be lowered when providing reasonable accommodations. Each situation will be reviewed on an individual case-by-case basis.

  • Confidentiality of Information

    NIACC Disability Services is committed to ensuring that all information and communication pertaining to a student's medical condition is maintained as confidential as required or permitted by law. The following guidelines about the treatment of such information have been adopted by NIACC Disability Services. These guidelines incorporate relevant state and federal regulations.

    1. 1. No one will have immediate access to student files in NIACC Disability Services except appropriate staff of NIACC Disability Services. Any information regarding a disability is considered confidential and will be shared only with others within the college who have a legitimate educational interest.
    2. 2. This information is protected by the Family Educational Rights and Privacy Act (FERPA).
    3. 3. Sensitive information in NIACC Disability Services student files will not be released except in accordance with federal and state laws.
    4. 4. A student's file may be released pursuant to a court order or subpoena.
    5. 5. If a student wishes to have information about his/her medical condition shared with others outside the college, the student must provide written authorization to the Director for NIACC Disability Services to release the information. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released. The student should also understand that there may be occasions when the Director for NIACC Disability Services will share information regarding a student's temporary medical condition at his/her discretion if circumstances necessitate the sharing of information and the Director has determined that there is an appropriate legitimate education interest involved.
    6. 6. A student has the right to review his/her own NIACC Disability Services file with reasonable notification.

    I have been informed of the policy regarding confidentiality and the release of information from my NIACC Disability Services file. I understand that NIACC Disability Services may release information from my file to be used in a confidential manner with appropriate college faculty & staff and officials who have a legitimate educational interest while I am a student at North Iowa Area Community College.