Services for Students with Disabilities
       Student Request for Assistance Form
      Date: _______________
      Your name: ___________________________ PSCC ID number: ___________
      Your address:
      Street: __________________________ City__________________ Zip ________
      Your email address: __________________Your phone number: ______________
Please use the back of this form if you need more space.
1.	Describe the situation (who is involved, what happened, date(s) of 
occurrence, etc.).  
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2.	What have you done to try to resolve the problem yourself? (Persons that 
you talked with, result of conversations, etc.).
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3.	How would you like to see the problem resolved? Please be specific.
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Reviewed by: ____________________ (SSWD Staff Member) Date: ___________
SSWD Staff Recommendation: 
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