Accessibility Resources Student Information Questionnaire

  • Complete and submit this form in its entirety. Alternatively, you may print the PDF, complete the form and deliver it to Accessibility Resources.

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

    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.

    Local Address

    Permanent Address


    I. Diagnostic Information


     

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


     


     


     


     


     

    Describe your academic skill level in the following areas.

    Reading
                            
    Writing
                       
    Math
                     
    Spelling
                    

    Describe your skill levels in the following areas.

    Organization
              
    Time Management
              
    Study Skills
               
    Self-advocacy
               
    Medication Management
               
    Motivation
                
    Punctuality
               
    Ability to Schedule/Keep Appts
               
    Ability to Complete Tasks on Time
               
    Ability to Follow Directions
               

    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.

    Caring for Oneself
            
    Talking
            
    Hearing
            
    Breathing
            
    Seeing
            
    Walking/Standing
            
    Lifting/Carrying
            
    Sitting
            
    Performing Manual Tasks
            
    Eating
            
    Working
            
    Interacting with Others
            
    Sleeping
            
    Learning
            
    Memorizing
            
    Concentrating
            
    Listening
            
    Attend Class
            
    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:

     

     

     

    III. Accommodations