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:
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.
Can we call you if necessary?
May we leave a message?
Current Academic Level:
Armed Forces Americas (except Canada)
Armed Forces Europe, Canada, Africa, Middle East
Armed Forces Pacific
District Of Columbia
Federated States Of Micronesia
Northern Mariana Islands
Reason for applying:
I have a disability and I am requesting accommodations
I think I might have a disability
I have a temporary disability
Please identify any disability/disabilities that you have been diagnosed with:
List current professionals involved, if applicable:Please provide name, address, and phone number
Current disability related medication(s), dosages, and side effects:
Please rate your understanding of your disability/disabilities:
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.
Describe in as much detail as possible how your disability currently impacts you in regard to the following:
Please rate your understanding of how your disability/disabilities impact you:
Please describe the accommodation(s) you have received in the past:
Please check where you received these accommodations:
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:
Will be sent via email
Will be sent via fax
Will be sent via regular mail
Will be hand delivered
Has already been submitted
This application for services was completed by:
Other (please specify)
If other, please specify: