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Submission of this form prior to starting at PSU will result in further correspondence from the campus Disability Services Coordinator to provide additional information concerning services. Early receipt of this form will allow for a more timely response to your request for services. This form is intended ONLY for those students with disabilities who require academic adjustments and auxiliary aids. Completion of this form is optional. All students should consult the PSU Office for Disability Services website for additional information. Visit Disability Services site »

The Pennsylvania State University encourages academically qualified students with disabilities to achieve full participation and integration of its educational programs. It is Penn State's policy not to discriminate against qualified persons with disabilities in its admissions policies and procedures or its educational programs, services, and activities. The University encourages students with disabilities to participate fully in its educational programs. 

Individuals who are seeking academic adjustments and/or auxiliary aids must self-disclose their need for academic adjustments and/or auxiliary aids to the Penn State location at which they are enrolled. To be eligible for academic adjustments and/or reasonable auxiliary aids, students must have a documented disability as defined by the Rehabilitation Act of 1973 or the Americans with Disabilities Act Amendments Act (ADA AA), 2008. The ADA AA defines a disability as a physical or mental impairment that substantially limits a major life activity. 

The receipt of this form does not constitute that the student has self-identified. Students are required to self-identify by contacting the Disability Contact Liaison. You may contact the Disability Services Coordinator, Michelle Peasley at mns136@psu.edu .

Name: [enter name]  

Home address: [enter street, city, state, zip]

Phone Number: [enter phone number with area code]

E-mail address: [enter e-mail address]

I am Requesting information regarding the following disability(ies)  (check all that apply):

[   ] Attention Deficit/Hyperactivity Disorder

[   ] Speech Impairment

[   ] Hard of Hearing/Deafness

[   ] Traumatic Brain Injury (TBI)

[   ] Learning Disorder

[   ] Visual Impairment

[   ] Psychiatric Disorder

[   ] Other (Please specify)

Student’s Signature [student signs here]

Date [enter month, day, year]

This publication is available in alternative media on request.

Steps to Register with Berks Disability Services

  1. Request or view documentation guidelines
    • Several Methods
    1. Visit Disability Services website »
    2. Contact Michelle Peasley at Penn State Berks at mns136@psu.edu
    3. Complete an Information Request Form
  2. Provide all required documentation to Disability Services (DS)
  3. Documentation could include psychological reports, verification forms, re-evaluation report, etc...
  4. Schedule an intake assessment with Michelle Peasley (mns136@psu.edu or 610-396-6410)
  5. After documentation is reviewed, additional information or documentation may be required. Submit additional documentation to Disability Services
  6. Discuss determination of documentation review and if student is eligible complete Responsibility Contract
  7. If student is eligible, schedule appointment at the beginning of each semester to receive accommodation letters. Students are responsible for providing letters to their professors and discussing reasonable accommodations with their professors.

Important Contacts

Office of Disability Services, Penn State Berks, Michelle Peasley, mns136@psu.edu

Phone: 610-396-6410 | Fax: 610-396-6402

Penn State Berks’ Learning Center, Franco 163, 610-396-6288

Visit Office of Vocational Rehabilitation website »  or call 800-442-0949