Disability Student Information Form

Disability Student Information Form

Your Name Surname:

Date of Birth:

Mobile Phone Number:

Email Address:

Your Advisor:

Your Faculty:

Your Department/Class:

Your Student Number:

Your Address (Residence):

Information Related to Your Disability

What is your disability?

Attention Deficit Hyperactivity Disorder

Language and Speech Disorder

Emotional Behavioral Disorder

Visual or Hearing Impairment

Visual Impairment

Hearing Impairment

Chronic Illness/Health Issue

Orthopedic (Physical) Disability

Autism/Asperger Syndrome

Learning Difficulty

Psychological Issues

Other:

Which areas do you have difficulties in?

Using hands

Vision

Hearing

Personal care

Concentration/Thinking

Speech

Understanding spoken language

Using stairs

Reading

Writing

Walking

Other:

What services do you need to ensure that your disability does not negatively affect your educational experience?

A helper for studying

Conducting classes in easily accessible classrooms

Providing course materials in alternative formats (audio recordings, Braille, electronic format)

A note-taker in class

Sign language interpreter

Campus orientation program

Library services

Psychological counseling

Providing exam materials in alternative formats

Assistive technology (such as listening devices, recording devices, computers, laptops)

Other: