Fillable Self-report-form CSUCI > Self-report form

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Self-report-form CSUCI > Self-report form

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State
University
DISABILITY
ACCOMMODATIONS
& SUPPORT SERVICES
CHANNEL
ISLANDS
Disability Accommodations & Support Services
One University Drive
Camarillo, CA 93012
Arroyo 210
Phone: 805-437-3331
Fax: 805-437-8529
SELF-REPORT FORM
Self-reporting your disability and how the disability impacts your everyday living and learning experience is an
important source of information when determining eligibility for Disability Accommodations and Support
Services (DASS). The information provided on this form will be interpreted and discussed at your new
student appointment with a DASS Transition and Retention Counselor. If the existence of a disability and the
need for accommodations are self-evident, this self-report form may be sufficient for establishing disability and
the need for accommodations. However, some supportive documentation from another source is typically
needed to establish eligibility.
Student Name:
Date:
1. In your own words, what is your understanding of your disability/diagnosis?
2. What are your challenges? When did you first notice these challenges?
3. Have you discussed your challenges/disability with an educational or medical professional?
Page 1 of 2
State
University
DISABILITY
ACCOMMODATIONS
& SUPPORT SERVICES
CHANNEL
ISLANDS
Disability Accommodations & Support Services
One University Drive
Camarillo, CA 93012
Arroyo 210
Phone: 805-437-3331
Fax: 805-437-8529
4. Have you received accommodations or support services at another school as a result of your
challenges/disability?
5. How does your disability/ diagnosis impact your everyday activities?
6. In your own words, describe how your disability affects you in an academic setting (i.e., test taking,
class attendance, taking notes, group work, social interactions, understanding materials, reading,
comprehension, etc.).
Page 2 of 2
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Self-report-form CSUCI Self-report form

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Completed 11 February 2020

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