Disability Intake Questionnaire Download this form -pdf You should complete this form before you visit with the Counselor for Disability Services. General InformationToday's Date* Enter today's date. Please use the following format: mm/dd/yyyyName* First Last Enter your full name.Birthdate* Enter your date of birth. Please use the following format: mm/dd/yyyyAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Enter a phone number where you can be reached.Email* Enter your email address.NIACC Entry DateEnter the date you will begin classes at NIACC.Entry Date* Semester of Entry*FallSpingSummerSelect the semester you will begin classes at NIACC.Disability InformationIn this section you will tell us about your disability.1. What diagnosed disability are you seeking accommodations?* Attention Deficit Disorder ADD / Attention Deficit Hyperactivity Disorder ADHD Blind / Visual Impairment Brain Injury Chronic Illness Deaf / Hard of Hearing (HOH) Learning Disability LD Mental Health Impairment Mobility Impairment Speech Impairment Other You can press the space bar to mark a checkbox. Check all that apply.1 a. Other disability not listed: Please specify.If your disability was not listed above, you can list it here.2. When was this disability first identified or diagnosed?*3. Are you taking any medications that might affect your attendance or performance at college?*YesNoYou can use the up and down arrow keys to select an option.3 a. You selected yes. How may these medications affect your physical, sensory, perceptual, behavioral or cognitive performance?*4. Please provide a descriptive narrative of your disability in your own words and explain how it affects you in an academic setting (and living situation if staying in the NIACC Residence Halls)*5. How does your condition impact you in classes regarding the following: Listening, note taking, speaking, writing, keyboarding, sitting, attendance?*6. How does your condition impact you in evaluations regarding the following: tests, papers, oral reports, group projects?*7. How does your condition impact you when doing out of class assignments in the following areas: reading, writing, calculating, keyboarding, library work?*8. How does your condition impact you when there are time constraints in the following area: timed tests, deadlines, class schedule:*9. How does your condition impact your mobility in the following areas: manipulating objects, transportation, getting around?*10. How does your condition impact you in other areas?*11. Have you received accommodations for this disability in the past?YesNo11 a. You selected yes. What auxiliary aids, assistive devices, support services, and accommodations have you used or are you currently using that are effective in lessening the impact of teh disabilty?Accommodation Approval AgreementI understand that completing this form is only the initial step in the accommodation process. Once I am registered with NIACC Disability Services, I will need to meet with a Disability Services Counselor each semester to request accommodations and complete Accommodation Letters for Faculty. I also understand that I am my own advocate. It is my responsibility to request accommodations and to notify instructors of my need for accommodations. It is also my responsibility to report any concerns I may have regarding accommodations to the Disability Services Office I understand that documentation of my disability must be provided to the Disability Services office before accommodations will be provided. I realize that I may need additional documentation upon transferring to another educational institution. It is my responsibility to consult with the transfer institution regarding their documentation requirements. I affirm that the information contained in this form is true and accurate to the best of my knowledge. If any information changes, I will notify the Disability Services Office immediately. Accommodation Approval Agreement* I have read and agree to the "Accommodation Approval Agreement" Disability Services in College StatementNorth Iowa Area Community College (NIACC) is committed to providing reasonable accommodations to qualified students with disabilities. These accommodations are provided to assist students with disabilities in accessing education at NIACC. Working in partnership with the student, the Disability Services Counselor will develop an individual plan for services that will include accommodations in testing and instruction. A student with disabilities must submit documentation to verify presence of a disability and request services each semester. Please note that program requirements will not be altered and standards will not be lowered. Disability Services in College Statement* I have read and fully understand the "Disability Services in College Statement". Statement of ConfidentialityNIACC Disability Services is committed to ensuring that all information and communication pertaining to a student's disability is maintained as confidential as required or permitted by law. The following guidelines about the treatment of such information have been adopted by NIACC Disability Services. These guidelines incorporate relevant state and federal regulations. 1. No one will have immediate access to student files in NIACC Disability Services except appropriate staff of NIACC Disability Services. Any information regarding a disability is considered confidential and will be shared only with others within the college who have a legitimate educational interest. 2. This information is protected by the Family Educational Rights and Privacy Act (FERPA). 3. Sensitive information in NIACC Disability Services student files will not be released except in accordance with federal and state laws. 4. A student's file may be released pursuant to a court order or subpoena. 5. If a student wishes to have information about his/her disability shared with others outside the college, the student must provide written authorization to the Counselor for NIACC Disability Services to release the information. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released. The student should also understand that there may be occasions when the Counselor for NIACC Disability Services will share information regarding a student's disability at his/her discretion if circumstances necessitate the sharing of information and the Counselor has determined that there is an appropriate legitimate education interest involved. 6. A student has the right to review his/her own NIACC Disability Services file with reasonable notification. I have been informed of the policy regarding confidentiality and the release of information from my NIACC Disability Services file. I understand that NIACC Disability Services may release information from my file to be used in a confidential manner with appropriate college faculty and officials who have a legitimate educational interest while I am a student at North Iowa Area Community College. Statement of Confidentiality* I have read the "Statement of Confidentiality" and fully understand it's terms and conditions. EmailThis field is for validation purposes and should be left unchanged.
