• 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:



    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.

    Academic Skill Level
     

     

     

     

     

    Describe your skill levels in the following areas.

    Skill Level











    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.

    Functional Limitation Activity Ranking
                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

    (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

     

    Please check where you received these accommodations: