New Student Intake Form to Start a File
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Bemidji State University Disability Services Office Sanford Hall #202 1500 Birchmont Drive NE #43 (218) 755-3883 E-Mail: disabilityservices@bemidjistate.edu Today’s Date________________________ Birth Date__________________________ Student ID No.______________________ Entering Term_______________________ E-Mail_____________________________ STUDENT WITH A DISABILITY SERVICES INTAKE INFORMATION GENERAL INFORMATION Name_____________________________________________________________________________ Address_________________________________________ Phone_____________________________ (Street and Number) (Home) __________________________________________________________________________________ (City) (State) (Zip Code) Major Area of Study__________________________________ Anticipated Graduation Date:________ What is the highest degree you plan to pursue? ______ Bachelor’s degree ______ Professional Degree (Check one) ______ Certification ______ Doctorate _______Master’s Degree ______ Non-degree sought Do either of your parent’s have a four year degree (Bachelor’s Degree or higher)? __________ DISABILITY INFORMATION What is your disability? (Check all that apply) _____Deaf/hard of hearing _____Motor impairment _____Blind/visually impaired _____Mental health _____Learning disability _____Chemical Dependency _____TBI Survivor _____Systemic Disability _____Speech impairment _____ADD/ADHD _____ Autism Spectrum _____Other (please specify) ________ When were you first diagnosed?________________________________________ What is the prognosis of your condition? _____Stable _____Likely to improve _____Degenerative _____Unknown Do you have periods of time when it is difficult for you to function due to migraine headaches, seizures, chronic pain or other conditions?_________ If the condition is not listed above, what specific condition affects your ability to attend class? ________________________________________________________________________________________ _______________________________________________________________________ ________________ If you have a seizure condition how often do you have seizures? ___________________________________ How long does it take you to recover from a seizure? ____________________________________________ What is the date of your last seizure? _______________________________________________________ What problems does your disabling condition cause in class?________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _______________________________________________________________________ _________________ How do you solve or compensate for these problems?______________________________________________ _______________________________________________________________________ _________________ Online Course work and D2L programming on campus Because many courses have an online component to them, if you use adaptive technology please answer the following questions: What type of assistive technology do you use? __________________________________________________ How does the technology work for you? What doesn’t work for your needs? ___________________________ _______________________________________________________________________________________ Do you work with the Department of Vocational Rehabilitation or Department of Rehabilitative Services? ________ What services do you receive from them? _______________________________________________________ _________________________________________________________________________________________ What software are you using and what version? __________________________________________________ _________________________________________________________________________________________ What computer system do you have and what type of internet connection do you use? __________________ ________________________________________________________________________________________ What previous experience do you have with online course work and were you using this technology? Please list all experiences: ________________________________________________________________________________ ____________________________________________________________________________________________ Have you used a chat room before? ______________ Were you able to navigate the chat room as needed? ____________________________________________________________________________________________ Were you able to navigate the online registration process on your own or did you need assistance? _____________ ____________________________________________________________________________________________ Why are you choosing to do online course work at this time? ___________________________________________ ____________________________________________________________________________________________ What are the advantages to you of taking online course work? __________________________________________ _____________________________________________________________________________________________ What are the disadvantages to you of taking online coursework? _________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ How familiar are you with the topic of your online course? ______________________________________________ What are your expectations of online courses:? ______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ EDUCATION INFORMATION High School: _____ Special education program _____ Mainstreamed Name of School and City:_________________________________________________ Undergraduate School: _____ Received _____ Did not receive accommodations (For Transfer Students Only) In order to better provide support for you please take a few moments and help us with this self-evaluation. Describe your academic skill level in the following areas. Reading Writing Math Spelling _____strong _____strong _____strong _____strong _____good _____good _____good _____good _____fair _____fair _____fair _____fair _____weak _____weak _____weak _____weak _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____good _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____fair _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak _____weak Describe your skill levels in the following areas. Organization Time Management Self-Starter Responsible Study Skills Self-advocacy Assertiveness Medication Management Disability Management Motivation Attitude Ability to get along with others Healthy Eating Habits Healthy Sleep Habits Punctuality Ability to Adjust to Change Ability to Accept Criticism Ability to Schedule/Keep Appts Ability to Complete Tasks on Time Ability to Follow Directions _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong _____strong What subjects were difficult for you in high school? ________________________________________________ How did you compensate for these difficulties? ____________________________________________________ __________________________________________________________________________________________ Did you take the college-prep track in high school? _________________ Please briefly describe any difficulties you have had with academics not necessarily directly related to your disability. (ie., struggle with math, writing or other subjects, have GED, have not been in school for several years etc. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Is there anything else you would like me to know that might better able me to provide academic support or disability accommodations to you while attending BSU? ___________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Academic Accommodations Have you had academic accommodations for your disability before? ___________ If yes, please indicate the accommodations you have received (ie. notetakers, etc.) and when you received them. Accommodation Received Interpreter Service (ASL or Cued Speech) Note Takers Tape Lectures in Lieu of Note Taker Reader Service Scribe Service Testing Out of Class Extended Test time Priority Registration What accommodations have you used in the past when taking exams? (Check all that apply) None Have test questions read Dictate my answers to writer Type my answers Extended time limit Large print exam When? Objective or Multiple Choice Exams Subjective or Essay/Short Answer Exams Please indicate any accommodations you have used for online course work (if any). Check all that apply. What accommodations have you used in the past when taking online courses? None Extended Test Time Large Print Exam Reader Program Speech Program to dictate answers Extended Assignment Deadlines Where did you use this accommodation? (Name of School) Will you need help accessing library materials due to a physical or visual disability? If yes, please describe what type of help you will need? __________________________________________________________________________ _________________________________________________________________ __________________________ FINANCIAL ASSISTANCE Have you applied for financial aid? ______ Are you eligible for Pell Grants or State Grants? __________ If not, please explain briefly. _______________________________________________________________________ _________________________________________________________________________________________ To help us if we need to work with other agencies, have you applied to any outside agencies for additional help with funding or other support? Please check all that apply and provide information for each. Name of Agency Name / Address / Telephone Number of Counselor Department of Rehabilitative Services State Services for the Blind Private Insurance Claim for Retraining _______________ County Social Services Social Worker (Please Indicate County of Origin) Veteran’s Officer _____________________ _____________________ The information contained in this form is true and accurate to the best of my knowledge. ______________________________ Student’s Signature ___________________________ Date ************************************************************************ FOR OFFICE USE ONLY: Type of Disability_________________________________ Documentation Ordered__________________________ Documentation Rec’d______________________________ Referral to TRIO/SSS Director for screening___________ Accommodation Eligibility Interpreter Service (ASL or Cued Speech) Note Takers Tape Lectures in Lieu of Note Taker Reader Service Scribe Service Testing Out of Class Extended Test time Priority Registration Handicap Parking Wheelchair storage Other Exam Accommodations No accommodations needed MC Essay Have test questions read Dictate answers to write/scribe Type my answers Extended testing time % extended Large print exams Other accommodations: Specifybelow Revised August 2013
