Student Information Questionnaire
Steps to Establish an Accommodation Plan:
1. Complete the Student Information Questionnaire (SIQ) form and return it to S5
Memorial Union, or disabilitycenter@missouri.edu. Be sure to fill out the form yourself
thoroughly and accurately.
2. Schedule an introductory meeting with an access advisor/coordinator, which will take
about an hour. Bring a list of questions, and be prepared to talk about your disability
and how it affects your learning.
3. Be prepared to provide documentation of your disability (also referred to as third party
documentation). Third party documentation may consist of an IEP/504 plan, recent
diagnostic evaluation, or a letter from a qualified professional that explains more about
your disability and how your disability impacts you.
4. Participate in a New Student Orientation (NSO). The orientation will provide you with
information about our office, explanations of policies and procedures, and
accommodation memos for professors.
5. Set up appointments with your professors, during their office hours. Present your
professor with your accommodation memo and have a conversation about your
accommodations to develop a plan for the semester.
6. Once you have received accommodations for your first semester, you can quickly and
easily renew your accommodation plan online for all following semesters.
All prospective student records will be kept on file for one (1) year.
Following that timeframe, files will be destroyed. If you have questions or concerns regarding
this policy, please contact our office.
______________________________________________________________________________________
S5 Memorial Union, Columbia, MO 65211 | 573-882-4696 | disabilitycenter@missouri.edu
Disability Center ~ Student Information Questionnaire
Today’s Date: ________________________
Name (Last, First, MI): _________________________________________________________________
Current Address: ______________________________________________________________________
Phone #: __________________ Student Id: ________________ User Id (pawprint): ______________
Reason for visit (check all that apply):
I have a disability and I am requesting accommodations
I think I might have a disability
Housing Accommodations
Other:
____________________________________________________________________________________
Student Status (check all that apply):
Incoming
Current
Freshman
Sophomore
Transfer
Mizzou Online
Junior
Senior
Graduate
Professional
Other: ____________________________________________________________________
Major: _____________________________
Semester Applying for: ________________
Minor: _____________________________
Part Time Student
Full Time Student
Disability(ies) (check all that apply):
Cognitive (e.g. ADHD, Brain Injury)
Learning (LD)
Neurological
Speech/Language
Vision
Development
Health
Hearing
Physical Dexterity/Mobility
Psychological
Other: ______________________________________
Do you receive Vocational Rehabilitation Services (VR)?
YES
NO
If yes, who is your counselor? _____________________________________________________
Do you receive Rehabilitation Services for the Blind (RSB)?
YES
NO
If yes, who is your counselor? _____________________________________________________
Veteran Status:
N/A
Veteran
Military Personnel
Families (spouse/dependents)
Please describe your specific disability?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How and when was your disability diagnosed and documented?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe how your disability currently impacts you in:
School:_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Work:________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Social/Personal:________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you have used accommodations in the past, what have you used?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What accommodations are you requesting (e.g. adaptive equipment, alternative format, note taking,
bus services, classroom/lab assistant, exam, housing, sign language, etc.)?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
If applicable, list the housing accommodations you are requesting for living on campus (e.g. wheelchair
accessible, visual alarms, etc.)?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Student Name (Print) __________________________________________________________________
Student Signature ___________________________________________ Date: _____________________
Office Use Only: Received by (initial): ____________ Date received: ______________________
Appointment scheduled (who/date/time): ______________________________________________
Disability Center Release of Information
PARENT/GUARDIAN RELEASE: The following statement addresses the right of a student’s individual
privacy. In the event a parent, step-parent or guardian inquires about or calls on behalf of a student, the
Disability Center must have a written release signed by the student to be able to speak with them. I give
the Disability Center permission to speak with my parents, step-parents or guardians about me and my
progress as a student registered in the MU Disability Center.
_____Agree _____Disagree
________________________________________________
Signature
Date
________________________
LEARNING CENTER RELEASE: The Learning Center provides tutoring by appointment for undergraduate
students who qualify under specific program requirements, including those who have a disability. To
assist the Learning Center with the application process, the Disability Center will release your name to
them, with your permission.
If you agree to have your name released to the Learning Center identifying you as a student registered
with Disability Center, please indicate below.
______Agree ______Disagree
________________________________________________
Signature
________________________
Date
Unless otherwise revoked, this authorization will remain in effect for the duration of my enrollment as a
student at the University of Missouri.
Title IX Statement
The University of Missouri’s Equal Employment/Education Opportunity policy [UM System CR&R 600.020], which is compliant
with Federal laws prohibiting discrimination, requires that faculty, student employees and staff members, with some
exceptions, report any known, learned or rumored incidents of sex discrimination, including; sexual harassment, sexual
misconduct, stalking on the basis of sex, dating/intimate partner violence or sexual exploitation and/or related experiences or
incidents. To report sexual misconduct or ask questions about the policies and procedures regarding sexual misconduct, please
submit the online reporting form at title9.missouri.edu/reporting or contact the Title IX coordinator, Linda Bennett, 573-8827915 or bennettli@missouri.edu.