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Questions

1.  

   What brings you to Disability Services

   I am looking for information - I want to know what my options are

   I am looking for accommodation - I need adjustments to engage in my studies

   Other (Specify Below)

   Additional Note or Comment
2.  

   Were you referred by someone?

   Yes, If yes, by whom? (Specify Below)

   No

   Additional Note or Comment
3.  

   Did you graduate from high school? * (Selection is Required)

   Yes If yes please provide the year and whether it was a STANDARD Diploma or a MODIFIED Diploma (Specify Below)

   No

   Additional Note or Comment
4.  

   Did you complete a GED? * (Selection is Required)

   Yes, specify year you completed GED (Specify Below)

   No

   Additional Note or Comment
5.  

   Have you used accommodations in the past?

   No

   Yes, in K-12 through an IEP or 504 Plan

   Yes, in a College or University setting

   Yes, through Employment

   Other (Specify Below)

   Additional Note or Comment
6.  

   FUNCTIONAL LIMITATIONS: I have difficulty or may need assistance with:

   Seeing: printed materials, overheads, chalk/whiteboard, program access, other

   Hearing: lectures, group discussions, speaking, other

   Learning: taking notes, In-class assignments, other

   Understanding: textbooks, lectures, discussions, handouts, graphs/charts

   Testing: completing on time, easily distracted, other

   Physical Activities: Sitting, stairs, manipulating objects, manual task, other

   Participation: Attending class regularly, focus/concentration, groups, other

   Communicating: with instructor, other

   Additional Note or Comment
7.  

   How do you rate your own self-advocacy skills

   I'm not sure what self-advocacy skills are

   I frequently have difficulty advocating for myself

   I am usually comfortable advocating for myself

   Comments (Specify Below)

   Additional Note or Comment
8. What is your understanding of how the accommodation process works? There are no wrong answers here.
9. If you need accommodation for the information session or initial appointment, please specify below