Office of Disability Services
Permission to Release Information
I understand that ODS may release information from my file to be used in a confidential manner with
appropriate University faculty and officials who have a legitimate interest while I am involved with Nicholls
State University. ODS staff maintains the right to contact the appropriate authorities if there is evidence judged
to be of an emergency nature which affects the safety of myself or someone else.
I have been informed of the policy regarding confidentiality and the release of information from my ODS file.
This consent may be revoked at any time upon written request.
Informed Consent
I am aware that ODS utilizes an electronic database, Titanium Schedule, to maintain my records and schedule
tests in the ODS office. This software is password protected and is only accessible by ODS staff. All data is
stored on a private wire server which is firewalled to specified Titanium users only. A specified staff person in
Computer Services maintains the server, but does not log-on to Titanium as a user.
Student Contract
I have received and agree to the terms stated in the Student Contract. I also understand non-compliance of the
Student Contract will result in penalty or termination of ODS services for the semester and/or future semesters.
By signing below, I acknowledge that I have read and discussed the above information with ODS staff.
_________________________________________________________________________
Student Signature / Date
_________________________________________________________________________
ODS Staff Member/ Date
Revised 01/05/12
m:services/disability packets/permission to release information form