Documentation Form Of Physical Disability - Student Development (Page 3 of 4) in pdf

Documentation Form Of Physical Disability - Student Development Page 3

Page 3 of 4

Documentation of Sensory,

Services for Students with Disabilities (SSD)

Physical and Medical Disabilities

Student Development Centre – Western University

Abilities & Activities

Mild

Moderate

Severe

Don’t

Impact

Know

To what degree does the disability directly affect the following physical and sensory capacities?

Hearing

Speech

Vision

Mobility

Dexterity

To what degree does the disability directly affect the following cognitive abilities?

Working memory

Long-term memory

Speed of information processing

Language use

Rational thinking and reasoning

To what degree is the disability associated with any of the following symptoms?

Pain

Fatigue

Poor Concentration

To what degree does the disability create functional limitations specific to the following academic

tasks when adaptations have not been made or assistive devices are not used?

Handwriting

Typing or keyboarding

Listening

Reading

Speaking

Does the disability affect the student’s tolerance for:

□

sitting for less than 50 minutes

□

sitting for more than 50 minutes

□

standing for more than 15 minutes

□

walking (cannot walk more than ____ meters at a time)

□

lifting (cannot lift more than _______kg)

□

reaching above shoulder level

□

twisting: neck, back, knees, wrists (please circle all that apply)

□

bending: neck, back, knees, wrists (please circle all that apply)

□

performing activities of daily living (please list):

Documentation Form Of Physical Disability - Student Development Page 3

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