Fillable Student-intake-form Accessibility Services Student Intake Form

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Student-intake-form Accessibility Services Student Intake Form

On average this form takes 36 minutes to complete

The Student-intake-form Accessibility Services Student Intake Form form is 4 pages long and contains:

  • 1 signature
  • 27 check-boxes
  • 129 other fields

Country of origin: US
File type: PDF

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I.
Accessibility Services
Student Intake Form
General Information
Middle: Last:First name:
A
ddress:
State:
Cell phone
:
Zip code:
Wor
k phone
:
(e.g.
, 999999999
9)
(e.g.
, 999999999
9)
City:
Home p
hone
:
(e.g.
, 999999999
9)
E-mail address:
Sta
tus:
Undergraduate:
Graduate:
Part-time
Master's
Full-time
Doctorate
Student ID:
Visiting s
tudent
T
erm:
Military:
Fall
Active du
ty
Wi
nter
Veteran
Spring
Reserve/Guard
Summer
Location: US Asia Europe
Major:
II. D
isability Informatio
n
Wh
at is your diagnosed disability? (Check all that apply
)
ADHD
Blind/Low vision
Chronic health
Deaf/Hard of hearing
Learning
Mental health
Mobility/Physical
Speech/Language
Temporary
Other
Please describe your disability and how it affects your performance as a student.
Please indicate the support service/accommodations you are requesting and how they will help you.
What kinds of special equipment or auxiliary aids do you use on a regular basis?
Agency Information
Are you receiving assistance from any outside agency (i.e. Department for the Blind and Vision Impaired,
Department of Rehabilitative Services, Social Security, etc.) for academic, career, or personal counseling
or support?
Yes No
1. Agency name:
Phone:
Fax:
(e.g., 9999999999)
(e.g., 9999999999)
City or county: Counselor’s name:
2. Agency name:
Phone:
(e.g., 9999999999)
Fax:
(e.g., 9999999999)
City or county:
Counselor’s name:
III. Support Services/Academic Adjustments
Check the services/academic adjustments that you have used before and those you feel will be
helpful to you at UMGC. You may check more than one.
HAVE USED HAV
E NOT VERY NOT
USED HELPFUL HELPFUL
Tutor
□ □ □ □
Note taker
□ □ □ □
□ □ □ □
Scribe
□ □ □ □
Recorded lectures
Reader
□ □ □ □
□ □ □ □
Extended test time
Testing in a separate
room
□ □ □ □
Audio
□ □ □ □
Textbooks/Materials
□ □ □ □
Spell checker
□ □ □ □
Word processor
□ □ □ □
Voice recognition
software
□ □ □ □
Adapted keyboard
□ □ □ □
CCTV
□ □ □ □
Talking calculator
□ □ □ □
Braille
□ □ □ □
Interpreter services
□ □ □ □
Enlarged print materials
□ □ □ □
IV. Educational Background
C
heck the tasks that you can do easily and those with which you have difficulty.
EASY TASK DIFFICULT TASK
Paying attention in class
□ □
Completing assignments
□ □
Taking notes
□ □
Memorizing
□ □
Managing time
□ □
Reading at a good rate of speed
□ □
Understanding what I read
□ □
Doing math calculations
□ □
Following directions
□ □
Spelling
□ □
Finishing tests on time
□ □
Putting thoughts into writing
□ □
Proofreading
□ □
Being motivated
□ □
Asking for help
□ □
Documentation of your disability is required in order to determine your eligibility for academic
accommodations. Please have your medical professional send Accessibility Services documentation of
your disability clearly outlining the functional limitation that would keep you from having an equal
opportunity while pursuing your educational program.
The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is
a federal law that protects the privacy of student education records. In accordance with FERPA,
UMGC may not disclose certain education records or information contained there without
written permission from the student. By signing below, I am indicating that Accessibility Services
has my permission to discuss my disability accommodations with my medical professional and
with UMGC departments for the purpose of arranging my academic accommodations.
S
ignature or e-signature required Date (mm/dd/yyyy)
Return this form to
UMGC Stateside
accessibilityservices@umuc.edu
Accessibility Services
3501 University Boulevard East
Adelphi, MD 20783
Phone: 240-684-2287
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Student-intake-form Accessibility Services Student Intake Form

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Completed 4 March 2020

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