Accessibility Resources - Student Self Report

Please complete this form prior to meeting with the Accessibility Resources staff at the University of Cincinnati - Blue Ash College.

Schedule an intake appointment with Accessibility Resources (513) 792-8625 and either complete this form online or bring a printed and completed version of the form along with any disability documentation you have (examples: IEP, psychological testing reports, medical reports, letter from physician, etc.)

During the intake appointment, the Accessibility Resources staff will review your information with you and discuss services and accommodations that may be appropriate.

Download PDF version of form

Demographic Data and Contact Information

Student Name

First Name Last Name

Date of Birth

Month Day Year

UC ID / M#

If you do not have one, you will be assigned one during orientation.)

Best phone to reach you

Area Code Phone Number

E-mail

(UC Email preferred)

Disability Disclosure

Primary Disability

Secondary Disability

Did you receive special education services (IEP/504 Plan) in grade school or high school?

Yes No

Please describe the services that were provided:

Student Self-Report Questions

Please answer the following questions about the impact of your disability. Please let us know if you require assistance with these questions.

What impact does your disability have on you in the academic setting? (examples: test taking, class attendance, taking notes, understanding materials, reading, comprehension, etc.)

Are there any other areas of University life that might be impacted by the disability? (examples: transportation, housing, building accessibility, parking, etc.)

What accommodations have you used in the past (examples: extended time on exams, note taker, quiet room, etc.? What was helpful? What was not?

If any, what assistive technology devices and/or auxiliary aids have been effective in providing equal access to educational opportunities? (example: tape recorder, calculator, audio textbooks etc.)

What is your intended major? Are there specific accommodations that need to be explored in that course of study?

If deemed eligible for services, what accommodations are you requesting from Disability Services?

Are you working with any external support networks or organizations? (examples: Vocational Rehabilitation Services, Veterans Services, Other)

Yes No

Need help finding employment during or after college? The new College-to-Career Counselor in Accessibility Resources can help. Would you like to meet them after your in-take meeting?

Yes No

Please list and describe what organizations or networks you are working with

Have you been prescribed medication applicable to your disability? How does the medication impact your daily functioning?

What are your strengths?

What are your challenges?

Is there any additional information which you would like to include within your self report?

Emergency Information

Emergency Contact Name

First Name Last Name

Emergency Contact Phone

Area Code Phone Number

Are there medical emergencies that may arise because of your disability?

Yes No

Please describe the emergency situation that could arise (including any medication required that medical personnel need to be aware of).

Signature

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Accessibility Resources – Student Self-Report