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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 is voluntary and all information will be kept confidential.
Individuals completing this form may expect to receive information about Disability Support Services and an icitation to mee with the advisor to discuss accommodative services.
Name:______Date:______Last First Middle
Student ID #:______Birth Date:______E-Mail:______
Address:______
Street City State Zip Code
Phone #:______
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 Degree(s) Seeking Anticipated Date of Graduation
Graduate/Professional:______
Date of enrollment at MO S&T 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 Substantial Impact Don’t Know
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:
______
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:
Disability Support Services
203 Norwood Hall
320 W 12th St
Rolla, MO 65409
573-341-6655-Phone
573-341-4172-Fax