This questionnaire is intended to help the diagnosing professional provide acceptable disability documentation and can be provided in place of a typed report. Written or printed document must be on official letterhead which includes the address, telephone number, name, title, and professional credentials of the evaluator. All typed documents must be accompanied with an official letterhead.

Student Information

Full Name:

CWID:

Date:

Major:

Present Academic Status: (Circle One) First Year Second Year Third Year Other