NEEDS ASSESSMENT

General Information

Student ID: 
Name:         
Address:    
City:    State:     Zip Code: 

Home Phone:   Work Phone:  
Cell Phone:        E-Mail:          
Note: If you do not have an E-mail address, please call the Accessibility Services Office at (303) 361-7395 to setup an appointment. 

Year of Birth:  Disability: 

Accommodations

What accommodation assistance did you receive in high school?:

How has your disability affected you in school (what did you struggle with?): 

What support services will you need? 

What is your experience with Computers?: 

What assistive technology are you currently using or have experience with?: 

Do you depend on the elevator to change floors?   Yes    No
If you answer "yes", and the elevator is out, we will make every attempt to relocate your classroom to the first floor. Please make sure your contact number in Banner is up to date.

Have you applied for Financial Aid?     Yes    No
Do you have a Vocational Rehabilitation (VR) counselor?       Yes    No

If you do have a counselor, please provide:

Name of counselor:   
Telephone number: 
Counselor's E-mail: 

Education and Career

If currently a high school or college student, give the name of the school or college you are attending:

If graduated from high school, give the year graduated:

How many years has it been since you’ve been in school?