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  • 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:

    Name:

    Dragon ID:

    Mnstate.edu Email Address:

    All official University business will be conducted via mnstate.edu email accounts. It is essential that you access, read and use your mnstate.edu account.

    Phone:

    Can we call you if necessary?

    May we leave a message?

    Birthday:  [None] Select a Date Delete the Date

    Gender:

    Current Academic Level:

    Local Address


    Street:

    City:

    State:

    Zip:

    Permanent Address


    Street:

    City:

    State:

    Zip:

    Emergency Contact


    Name:

    Phone:

    Reason for applying:
     Other:

    I. Diagnostic Information

    Please identify any disability/disabilities that you have been diagnosed with:

     

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

    Psychologist:  

    Psychiatrist:  

    Family Doctor:  

    Other:  

    Current disability related medication(s), dosages, and side effects:

     

    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)
       
                                        
       
                                        
       
                                        

     

    Additional Comments:

     

    Current Impact Statement

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

    Learning:  

    Work:  

    Social/Personal:  

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

                                                 

    III. Accommodations

    Please describe the accommodation(s) you have received in the past:

     

    Please check where you received these accommodations:


                                                

    Additional Comments:

     

    Please list the accommodations you are requesting (e.g. adaptive equipment, alternate format, note taking, exam accommodations, sign language interpreter, etc.). Please include the accommodation requested, as well as the reason for that accommodation.

     

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

                                                 

    Please list any assistive technology you have used in the past:

     

    Please identify any other challenges in the school environment you would like to discuss during the intake interview:

     

    Documentation from a qualified professional:

    This application for services was completed by:

    If other, please specify: