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:

Recommended classroom/course accommodations (Providers must state specific accommodations)