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 self‑identify 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:
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
Motivation/self-initiative
