E. Intersystem (existing between two or more systems)
□ Alcohol/substance addiction and recovery: students who are recovering from drug or
alcohol or substance abuse or who are in substance abuse treatment programs
□ Complex Chronic Medical Condition: a medical condition that significantly affects
multiple systems of the body. This would not include those with temporary disabilities.
□ Traumatic brain injury: an injury caused by an external physical force (concussion) or
from certain medical conditions (aneurysm, anoxia brain tumors, encephalitis, stroke) with
resulting mild, moderate or severe disabilities in one or more areas (abstract thinking,
attention, cognition, information processing, judgment, language, memory, motor abilities,
perceptual, physical functions, problem solving, psychosocial behavior, reasoning,
sensory, speech). The term does not include injuries that are congenital or birth-related.
F. Temporary Disabilities
□ A transitory impairment with an actual or expected duration of six months or less.
Examples include bone fractures, sprains, torn ligaments, post-surgical recoveries,
significant illness, etc.
□ Pregnancy-related condition.
G. Multiple Disabilities
□ A student with two or more disabilities.
□ Please specify:__________________________________________________________
2. Specify the diagnosis or type of disability based on the category above:
3. Please check all that apply:
□ I use a wheelchair.
□ I use assistive mobility devices (braces, crutches, cane, or prosthesis).
□ I wear a hearing aid.
□ I need to read lips of instructors.
□ I have difficulty reading the blackboard/whiteboard.
□ I have difficulty taking notes in class.
□ I have difficulty writing.
□ I have difficulty standing for long periods of time.
□ I tire easily when I walk distances.
□ I have difficulty walking up/down stairs.
□ Please describe any other mobility or disability related difficulties you are currently