Post-Admission Self-Identification form Voluntary Declaration of a Disability
Missouri University of Science and Technology (Missouri S&T) is committed to providing quality education for all individuals. If you
have a permanent or temporary disabling condition that may require special attention or services, please complete this form. Doing
so in voluntary and all information will be kept confidential.
Information about Disability Support Services and the required disability documentation, will be went to individuals who complete
this form and anyone else who requests this information
Demographic Data
Name:_____________________________________________________________ Date:_____________
Last
First
Middle
Student ID #:_____________________ Birth Date:_____________
E-Mail:_____________________
Local Address:_________________________________________________________________________
Street
City
State
Zip Code
Permanent Address:____________________________________________________________________
Street
City
State
Zip Code
Local Phone #:__________________ Permanent #_________________
Cell #:__________________
Do you receive Vocational Rehabilitation Services? Yes
No
If yes, who is your counselor?________________________________________________________
Student Status
Are you planning to attend new student Orientation (PRO)/Transfer Orientation? Yes:____ No:____
Will you need accommodations for the math placement exam? Yes:____ No:____
Have you been admitted to the University of Missouri Science and Technology? Yes:___ No:____
Are you currently enrolled in courses? Yes:____ No:____
Are you a transfer student from another campus/institution? Yes:____ No:____
Please circle your academic information below:
Freshman Sophomore Junior Senior Masters Doctoral Professional Other:________________
Undergraduate:_______________________
Date of enrollment at MO S&T
Graduate/Professional:__________________
Date of enrollment at MO S&T
___________________
_____________________
Degree(s) Seeking
Anticipated Date of Graduation
___________________
______________________
Degree(s) Seeking
Anticipated Date of Graduation
Disability Information:
Please state your disability(ies) ___________________________________________________________
_____________________________________________________________________________________
Please state the date of original diagnosis:__________________________________________________
Name the Professional(s) treating the disability(ies) stated above:_______________________________
_____________________________________________________________________________________
Please describe how your disability affects you both outside and inside the classroom, including exam and studying
situations:__________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Service History:
Please check/describe any services you have received in the past under “previously received.” Please check
those services you are interested in requesting at University of Missouri Science and technology.
Support Services & Accommodations
Previously Received (please describe)
Requesting at MO S&T
Adaptive Equipment (e.g. assistive
listening device, CC-TV)
Alternate Format (e.g. digital text,
braille, enlarged text)
Classroom/ Lab assistant
Exam Accommodations (e.g.
extended time, separate space,
reader, scribe)
Housing accommodations
Sign language
interpreting/Captioning
Any other information you would like to share:______________________________________
______________________________________________________________________________
______________________________________________________________________________
Functional Limitations: Please check any of the major life activities listed below that you believe are affected as
a result of your diagnosed condition(s). Please indicate the level of limitations you experience as a result of this
condition(s).
Life Activity
No impact
Moderate Impact
Attending Class
Breathing
Calculating
Caring for oneself
Concentrating
Eating
Hearing
Interacting w/others
Learning
Lifting/Carrying
Making, keeping
appointments
Managing Distractions
Meeting Deadlines
Memorizing
Organization
Performing Manual
Task
Reaching
Reading
Seeing
Sitting
Sleeping
Spelling
Stress Management
Taking Exams
Talking
Thinking
Walking/Standing
Working
Writing
Any other information you would like to share:
Substantial Impact
Don’t Know
I understand that to complete my registration I must provide documentation of my disability, and meet with an advisor.
Student Signature:_______________________________________________ Date:_________________
If you have any questions please contact:
Connie Arthur
Advisor
Disability Support Services
203 Norwood Hall
320 W 12th St
Rolla, MO 65409
573-341-6655-Phone
573-341-6179-Fax
dss@mst.edu
www.dss.mst.edu