Okanagan College Accessibility Services Intake & Self-Assessment Form
Preferred Student Name: ___________________________ Pronouns: _______________
Student No.: ____________________ Student Phone No.: _________________________
Student Email: ___________________________Program: ____________________________
Campus: Vernon Kelowna Penticton Salmon Arm Distance
Do you selfidentify as an Indigenous person in Canada such as First Nation, Métis or
Inuit? Yes No
Diagnosed/Documented Disability (check all that apply):
Choose not to disclose at this time
ADD/ADHD
Asperger’s/Autism/PDD-NOS
Chronic Health/Medical Condition
Deaf/Hard of Hearing
Head Injury (i.e. Concussion(s),
Traumatic Brain Injury)
Learning Disability (i.e. Dyslexia,
Dysgraphia)
Mental Health (i.e. Anxiety
Disorder, Bipolar Disorder,
Depression, Schizophrenia)
Mobility Impairment
Visual Impairment (i.e. Low
Vision, Legally Blind)
Other (please indicate):
____________________________
Self-Assessment of Functional Limitations
Please check the box that most accurately describes the impact that your disability has on the
following skills/abilities:
Skill/Ability
No
Impact
Mild
Impact
Moderate
Impact
Severe
Impact
Not
Applicable
Cognitive
Attention/concentration
Long-term memory
Short-term memory
Executive functioning
Information processing (speed of speech,
thought, understanding)
Ability to manage auditory distractions
Ability to manage visual distractions
Ability to manage internal distractions
Judgement (anticipating the impact of
your behaviours on self and others)
Managing brain fog (mental malaise)
Planning, organizing, prioritizing, time
management
Multi-tasking
Motivation/self-initiative
Y
e
s
Y
e
s
Y
e
s
Mobility/Physical
Fine hand movements, grasping,
dexterity
Bending, lifting, kneeling, carrying
Sitting for long periods of time
Standing for short periods of time
Standing for long periods of time
Managing physical pain
Mobility (walking, running, climbing stairs)
Repetitive body movements (e.g. pacing,
hand flicking, twisting, spinning, rocking,
etc.)
Managing physical fidgets/tics
Drowsiness from interrupted sleep
patterns or lack of sleep
Dizziness, fainting, seizures
Muscular control and coordination
Grasping a pen/writing on paper/writing
legibly
Typing on a keyboard
Frequent need to use restroom
Tolerance to time without food/water
intake
Sensory
Participating in/understanding verbal
communication
Participating in/understanding nonverbal
communication
Understanding/hearing information
presented through speakers/technology
Ability to communicate in noisy
environments
Hyperactivity
Hearing lectures/understanding auditory
information
Seeing a screen/information at close range
Seeing the instructor/screen/ information
at long range
Sensitivity to light, sound, touch, smell,
taste, movement
Seeing/discriminating between different
colours
Social/Emotional
Stress management during class
Stress management during tests
Communication with classmates
Participating in/understanding social
interaction
Speaking in front of groups/ability to
perform class presentations
In-class and group work interaction
Picking up on social cues, understanding
conversational norms
Fluctuating/low mood, ability to moderate
mood
Tolerating frustration/irritability
Managing flashbacks/trauma
responses/panic attacks/episodes
Flexibility & adapting to change
Academic Skills
Ability to complete tests on time
Regular/consistent attendance
Ability to complete a full course load
Follow-through/ability to follow
instructions
Reading/understanding information on a
screen
Reading/understanding information on
paper
Spelling commonly misspelled words
(homonyms, synonyms, heteronyms, etc.)
Spelling more complicated/new/ subject
specific words
Mental math calculations (addition,
subtraction, multiplication, division)
Formula-based math calculations (without
calculator)
Formula-based math calculations (with
calculator)
Other (Please list below)
Please provide any additional comments regarding functional limitations:
Have you ever had academic accommodations before (in grade school, high school, post-
secondary)?
No Uncertain Yes (please specify below)
Have you developed any strategies to help you manage any particular learning challenges?
No Uncertain Yes (please specify below)
Have you used assistive software and/or technology to offset the impact of the disability on your
studies (e.g. Read & Write Gold, Kurzweil, Dragon Naturally Speaking, Zoom Text, etc.)?
No Uncertain Yes (please specify below)
Have you used any assistive devices in the past (e.g. back support, an ergonomic chair, etc.)?
No Uncertain Yes (please specify below)
Does your program contain a practicum/clinical placement, work experience, service learning, or
co-op? Yes No
Would you like more information or referrals relating to the following? (Check all that apply):
Anxiety
Gender/sexuality
Housing
Nutrition & food security
Disability and
employment
Stress management
Time management/
organization
Study skills
Y
e
s