• 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.

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    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
    Reading

     

           

    Writing
            

    Math
            

    Spelling
            

    Describe your skill levels in the following areas.

    Skill Level
    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.

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

    Activity Rank
    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:

     

     

     

    III. Accommodations

     

    Please check where you received these accommodations: