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KENTUCKY STATE UNIVERSITY
HOUSING ACCOMMODATIONS POLICY DATE
| Questionnaire |
| Briefly describe your disability and how it affects you in an educational setting: |
| Date diagnosed: |
| Include a list of all testing and assessment instruments used in diagnosis evaluation report. NOTE: Test instruments may not apply to physical or sensory disabilities of a permanent or unchanging nature. |
| Describe present symptoms that fit the criteria for this diagnosis: |
| Describe the symptoms related to the student’s condition that cause significant impairment to academic performance and major life activity: |
| List the student’s current medications(s), dosage, frequency, and adverse side effects: |
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