More Information.
More details.Hide details.
  • Student Information Questionnaire

Accessibility Resources

  • Print
  • 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 email accounts. It is essential that you access, read and use your 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: