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 MSUM email accounts. It is essential that you access, read and use your go.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

     

                    

     

     

     

    If you do not receive confirmation to your email that this form was submitted successfully, please contact the Accessibility Resources Office.