Accessibility Services Department Intake Form (Page 2 of 3) in pdf

Accessibility Services Department Intake Form Page 2

3. In what ways have you struggled academically?

________________________________________________________________________

4. Were you ever held back a grade or repeated a course?

a. Yes

b. No

5. Were you ever in special education, resource classes, or received accommodations?

a. Yes

b. No

6. If yes, please explain: _____________________________________________________

Did you receive any of the following academic helps in your previous educational

experiences?

a. More time for exams

b. Books on tape or readers

c. Distraction-reduced testing environments

d. Others (please describe):

_______________________________________________________________

8. Are you currently registered or working with Vocational Rehabilitation?

a. Yes

b. No

9. Are you a Veteran?

a. Yes

b. No

10. Are you employed?

a. Yes How many hours? __________

b. No

11. Do you currently have any other medical concerns that affect your learning experience?

a. Yes

b. No

If yes, What?____________________________________________________________

12. Are you taking any medications?

a. Yes

b. No

Are you experiencing any side effects?

________________________________________________________________________

9/15/14

Accessibility Services Department Intake Form Page 2