• Student Information Questionnaire

Disability Resource Center

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  • Student Information Questionnaire

    Complete and submit this form in its entirety. Alternatively, you may print the PDF, complete the form and deliver it to the Disability Resource Center, FR 154.

    I have reviewed the Rights and Responsibilities. My electronic signature on this form signifies I have read and agree to my Rights and Responsibilities.

    Type your full legal name:



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    I. Diagnostic Information

     

    List current professionals involved, if applicable:
    Please provide name, address, and phone number

     

     

     

     

     

     

    Please rate your understanding of your disability/disabilities:

                                                                  

     

    II. Functional Limitations

    Functional limitation is a term given to the restriction or lack of ability in performing an action or activity.

    Functional Limitations: Please check any of the major life activities listed below that you believe are affected as a result of your diagnosed condition(s). Please indicate level of limitation you believe you experience as a result of the condition.

    1 = No Impact 2 = Mild/Moderate Impact 3 = Substantial Impact

    Caring for Oneself  
                                                            
    Talking  
                                                            
    Hearing  
                                                            
    Breathing  
                                                            
    Seeing  
                                                            
    Walking/Standing  
                                                         
    Lifting/Carrying  
                                                         
    Sitting  
                                                         
    Performing Manual Tasks  
                                                         
    Eating  
                                                         
    Working  
                                                         
    Interacting with Others  
                                                         
    Sleeping  
                                                         
    Learning  
                                                         
    Reading  
                                                         
    Writing/Spelling  
                                                         
    Calculating  
                                                         
    Memorizing  
                                                         
    Concentrating  
                                                         
    Listening  
                                                         
    Other: (please specify below)
       
                                                         
       
                                                         
       
                                                         

     

     

     

    Current Impact Statement

    Describe in as much detail as possible how your disability currently impacts you in regard to the following:

     

     

     

    Please rate your understanding of how your disability/disabilities impact you:

                                                                  

    III. Accommodations

     

    Please check where you received these accommodations:


                                                                 

     

     

    Please rate your knowledge of the accommodations needed to reduce/remove the barriers created by your disability/disabilities: