TTY (931) 221-6278

FAX (931) 221-7102

In order for students with disabilities to register with The Office of Disability Services and request academic accommodation, this intake form must be completed. We encourage you to provide complete, candid and realistic information concerning the nature of your disability, special needs, and any support services needed in order for you to successfully begin and/or continue your studies at Austin Peay State University. Please be advised that this form is considered confidential in nature and will be retained as such. Information provided on this form has no bearing on admission determination.

Date ______________________________________

Name ____________________________________________________ Social Security #_______________________________

Address___________________________________________________ Home Phone (____)__________________________

City and State ______________________________________ County______________________ Zip________________

Date of Birth ________________________________ E-Mail _______________________________________________

Race (optional): Please place an (X) in the box that applies:

	African American			American Indian/Alaskan Native			Asian/Pacific Islander
	Hispanic			White			Other

What is your classification? Please place an (X) in the box that applies:

	Freshman			Sophomore			Junior			Senior
	Re-Admit			Transfer			Graduate			Other

If you selected other, please explain:_________________________________________________________________________

_________________________________________________________________________________________________________

Intended Major:
Advisor:

Place an (X) in the boxes that apply to you: Do you require the use of the following:

Attention Deficit Hyperactive Disorder:			Accessible Parking:
Hearing Impairment:			Adaptive Equipment:
Learning Disability:			Crutches:
Medical Disability:			Interpreters:
Mobility/Orthopedic Impairment:			Personal Attendant:
Psychological/Psychiatric:			Prosthesis:
Speech/Language Impairment:			Walker:
Traumatic Brain Injury:			Wheelchair (please circle one) manual or motorized
Visual Impairment:			Other (specify):

Medical Diagnosis of your disability:

Date of onset of disability and/or diagnosis:

Medications:

Please place an (X) by all agencies that you are currently receiving services from:

Department of Rehabilitation Services:		State: County: Counselor: Phone:
Veteran’s Administration:		State: Counselor: Phone:
Other:		State: County: Counselor: Phone:

Please list any academic accommodations and/or support services that you have previously received:_______________________

_________________________________________________________________________________________________________

Please explain how you cope with your immediate environment as well as within an educational setting. Be sure to include any coping methods, which you employ (such as modified facilities, special equipment, communication methods, or unusual methods of handling situations). As an outline, you might describe your daily routine and/or how you adapt your abilities to be as mobile and as independent as possible (attach additional page if necessary).

_________________________________________________________________________________________________________

Information shared with The Office of Disability Services will be kept confidential unless you authorize release and exchange of specified information. Completion of this form does not guarantee academic accommodations and it is your responsibility to schedule an intake with our office to discuss the services and/or academic accommodations available. You MUST provide professional documentation to support your disability in order to qualify for academic accommodations. Accommodations can be provided only after these conditions are met. It is also your responsibility to contact instructors prior to each semester. This form is completed in consultation with the staff of the Disability Services Office. You should schedule an appointment with the Office of Disability Services as soon as you arrive on campus to discuss accommodations.

Your signature ___________________________________________________Date______________________________________

Person completing form if other than self:

Name__________________________________________________________ Relationship ________________________________

Revised 10/04/2005