Office of Disability Services - Student Intake Form

GENERAL INFORMATION

Name: *

Address: *

Apartment Number:

City: *

State: *

Zipcode: *

Telephone (home): *

Telephone (other): *

Last 4 Digits of SSN: *

Birth Date: *

E-mail Address: *

Please read and initial the following (to be completed by the student)

It is the student's responsibility to voluntarily and confidentially disclose information regarding the nature and extent of their qualifying disability. The college does not assume responsibility for providing accommodations or services to students who have not identified themselves as having a qualifying disability.

Nature and Extent: * (initials)

Disclosure
I do hereby give my permission for the Disability Services Office to act as an advocate on my behalf with my instructors, vocational rehabilitation counselor, and other significant FSU/Pierpont Staff members. I understand that it is my responsibility to meet with each of my instructors to discuss and request accommodations.

Disclosure: * (initials)

Parental Consent
I give my permission for the staff in the Disability Services Office to speak with my parent/s or guardian concerning my activities at FSU/Pierpont.

Parental Consent: * (initials)

Parental Consent Permission: *

Parent/Guardian's Name: *

Contact Information: *

How would you describe the help and support that you receive at home pertaining to school: *

What is your classification: *

If you selected other, please explain:

Intended Major: *

Advisor: *

Anticipated Graduation Date: *

MEDICAL BACKGROUND

What is your diagnosed disability: *

Describe your disability and how it affects your performance as a student: *

Other Disabilities: *

How do you cope with the limitations of your disability: *

Are you currently, or have you ever been, a client of West Virginia Department of Rehabilition and would you like to be referred: *

Check the tasks that you CAN DO and those in which you have difficulty: *

	Can	Difficult
Works well with others
Communicates well with others
Paying attention in class
Completing assignments
Taking notes
Memorizing
Managing time
Reading comprehension
Doing math calculations
Doing math word problems
Following directions
Spelling
Finishing tests on time
Putting thoughts into writing
Proofreading
Being motivated

Did you receive accommodations in high school: *

If yes, please list accommodations you received:

Have you received tutoring: *

If yes, please list what subjects:

Have you ever been trained on assistive reading software: *

Yes

List any other assistive technology you have been trained on:

How would you rank your study habits?: *

Have you been taught how to study: *

How much time do you usually study per day: *

Think about the following learning tools/accommodations; check those accommodations that apply to you: *

	Have Used	Might Help	Does Not Help	Do Not Need
Tutoring
Testing accommodations (extended time, separate quiet place, reader, scribe)
Note taking assistance
Books in alternate format
Enlarged text
Braille
Screen reading software
Magnification software
Speech recognition software
Transcribing
Tape recorder in class
Sign Language Interpreter
Scribe
Word processor
Adapted keyboard
CCTV/V-Tek
Talking calculator
Assistive Listening Device Phonic Ear

Physical accessibility assistance (please describe): *

Housing accommodations (please describe): *

Other (please list): *

Information shared with The Office of Disability Services will be kept confidential unless you authorize a release and exchange of specified information. Completion of this form does not guarantee academic accommodations and it is your responsibility to schedule an intake with our office to discuss the services and/or academic accommodations available. You MUST provide professional documentation to support your disability in order to qualify for academic accommodations. Accommodations can be provided only after these conditions are met. It is also your responsibility to contact instructors prior to each semester. This form is to be completed in consultation with the staff of the Office of Disability Services.

By submitting this form, you are acknowledging that all information is accurate.: *

I acknowlege all information is correct and accurate

Person completing form if other than self

Name:

Relationship:

(Must be completed by the student) I understand that if I am not enrolled in classes for four consecutive terms, my file and all its contents will be shredded.

Student Initials: *

Fairmont State University and Pierpont Community & Technical College are Equal Opportunity, Affirmative Action Institutions.

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1201 Locust Avenue, Fairmont, WV 26554 Tel: 304-367-4892
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