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INTERVIEW FORM COMMUNITY COLLEGE OF ALLEGHENY COUNTY (Community College of Allegheny County)

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COMMUNITY COLLEGE OF ALLEGHENY COUNTY
Supportive Services Supportive Services Supportive Services Supportive Services
Allegheny Campus Boyce Campus North Campus South Campus
808 Ridge Avenue 595 Beatty Road 8701 Perry Highway 1750 Clairton Rd
Pittsburgh, PA 15212 Monroeville, PA 15146 Pittsburgh, PA 15237 West Mifflin, PA 15122
OUR GOAL IS YOUR SUCCESS. Ph: 412.237.4612 Ph: 724.325.6604 Ph: 412.369.3686 Ph: 412.469.6215
Fax: 412.237.2721 Fax: 724.325.6733 Fax: 412.369.3661 Fax: 412.469.6357
Student Name: __________________________________________________ ID#: _______________________________
Birth Date: __________________________ Mobile Phone: ___________________ Email: _______________________
Emergency Contact: ______________________________________________ Phone: ______________________
Have you ever been tested for a Learning Difference (LD)? ⎕ Yes ⎕ No
Are you transferring from another college or university? ⎕ Yes ⎕ No
OVR Counselor: _________________________________ Needs referral ⎕
SELF-ASSESSMENT
So that we may best understand your needs, please indicate the disability area(s) for which you are requesting
accommodations:
ADHD (hyperactive/impulsive, inattentive, combined type)
Hearing Impairment
Autism Spectrum Disorder
Medical
Blind/Visual Impairment
Psychological/Emotional
Brain Injury (Acquired or Traumatic)
Speech/Language Impairment
Deaf
Temporary
Learning Disability
Describe how your disability effects your ability to function in:
Academic Setting
__________________________________________________________________________________________________
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Social/Personal Settings:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Employment Setting:
__________________________________________________________________________________________________
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INTERVIEW FORM
CCAC-SO-20SP
Disability Information: Please indicate which tasks you feel are a problem. There are no right or wrong answers. Your
answers help us determine which supports are most appropriate for you:
Paying attention in class
Completing assignments on-time
Taking notes
Reading at a good pace
Time management
Spelling
Understanding what you read
Solving math problems
Following directions
Putting thoughts into writing
Finishing tests or exams on time
Memorizing information
Proofreading essays
Getting/Staying Motivated
Asking for help
Accommodation History: If you have a disability and have ever used accommodations and/or auxiliary aids/services in
high school or at another institution, please indicate the type below.
Accessible furniture
FM System/ classroom amplification device
Accessible transportation
Note-taking assistance
Alternative text-book format (e-text)
Reader for quizzes/exams
Audio recording of lectures
Scribe for exams/quizzes
Other assistive technology devices (please List)
__________________________________________________________________________________________________
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Requested Accommodations: Please list the accommodations and/or auxiliary aids/services you might need to pursue
your academic career at CCAC.
Please note that an appropriate accommodation plan will be developed based on data collected from diagnostic reports and/or information gathered during the
initial interview process. Appropriate accommodations are determined by the Office of Supportive Services and may or may not be reflective of past
accommodations.
By signing below, I understand the information submitted to Disability Services is confidential and will not be placed
in my academic record. I understand that it is my responsibility to review the OSS Student Handbook. I am aware of
the availability of OSS Student Handbook on-line and have the right to request a hardcopy at any time.
Student Signature: __________________________________________________ Date: ___________________
The Community College of Allegheny County adheres to Title V, Section 504 of the Rehabilitation Act of 1973 and the
guidelines of the Americans with Disabilities Act (ADA).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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CCAC-SO-20SP
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NOTES:
CCAC-SO-20SP
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INTERVIEW FORM COMMUNITY COLLEGE OF ALLEGHENY COUNTY (Community College of Allegheny County)

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Completed 26 July 2020

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