Disability Services Registration Form

Disability Services Registration Form Prospective Students: If you are requesting accommodations for a campus visit or any part of the admissions process, please indicate so in the Other Accommodations section on page 6. Otherwise, consideration of a student s accommodation requests generally will not begin before s/he accepts an admissions offer from Columbia. However, we can provide information regarding services, disability documentation guidelines, campus accessibility, or to meet with you to discuss these or other disability related concerns. Steps in the Disability Services (DS) registration process for Current Students: 1. Complete this form and submit disability documentation. 2. Please refer to the documentation guidelines for your disability type, available on our website (www.health.columbia.edu/ods) 3. Please note that review of students requests cannot begin until all required paperwork is submitted. **Visiting students must also submit confirmation of approved accommodation from their home school. 4. DS staff reviews students requests (this may take up to three weeks) 5. Students will be contacted by a DS Coordinator to discuss next steps for arranging accommodations. How disability accommodations are determined at Columbia: Accommodations are determined following an individualized assessment of each request. Among the factors considered in determining appropriate accommodations for students are: 1. The nature of the student s disability; 2. Accommodations that have worked for that student in the past; 3. Whether the requested accommodations will allow the student to effectively access and participate in the course or program; 4. Whether the requested accommodations will alter the essential requirements of the course or program. The sooner the better! Once eligibility is determined (this can take 3 weeks), services may then take up to an additional 2-3 weeks to arrange accommodations, so it s a good idea to complete your registration as soon as possible. If you have any questions regarding your status in the meantime, you can call DS at 212 854-2388 or email us at disability@columbia.edu. Students who do not have to submit this form are: those requesting only Housing Accommodations (find the appropriate form at http://health.columbia.edu/services/ods/housing#housing_requestforms); those already registered with Disability Services who wish to request supplemental accommodations. The forms for these requests are available online at http://health.columbia.edu; Barnard, Teacher s College, UTS, or JTS (not GS joint degree) students. These students must request accommodations at their respective institution s disability services office. Have questions? Please complete as much of the Registration form as you can and submit to DS for initial consideration. If you want to speak to someone before you register, please indicate this on page 7. Last updated August 2012 1

Disability Services Registration Form I. Student Information Name: UNI: Date of Birth: Gender: Today s Date: Current Address: Phone # (Preferred): If you do not have a CU email, please provide an alternate email address: Note: all communication from DS will be sent to your CU email address once one is assigned. II. Referral Information Please indicate how you heard about Disability Services (check all that apply): Columbia Website Friend or Family Member Self Professor/ TA Athletics Department Academic Advisor/Dean Counseling and Psychological Services (CPS) or CUMC Mental Health Services Medical Services or CUMC Student Health Services If referred from another department at Columbia, please indicate name of person: III. Academic Information A. First semester (or anticipated) at Columbia: B. Specify your school/program at Columbia (check all that apply): Columbia College SEAS Undergraduate Continuing Education/Graduate/Professional School School: Program: High School Program: Program: School of General Studies - Undergraduate School of General Studies - Postbaccalaureate Premedical Program Specify which session you will be attending (circle one): Session I Will you live on campus? YES Visiting Student Specify home university: Semester(s) you will attend CU: I am a prospective student For which School/Program: NO Session II 2

C. Check all that apply: I am an International student I am an athlete (specify team affiliation): I am a military veteran (specify VA affiliation, if applicable): D. Please provide any information about your program that you feel is important and related to your request: IV. Previous Schools and Accommodations Previous School(s) Attended Dates Attended (From To) Approved Disability Accommodations and Services V. Disability Information Specify your disability type (check all that are applicable): Physical Psychological Chronic Medical Condition Specify: Specify: Specify: Deaf or Hard-of Hearing Blind or Low Vision Attention Deficit/Hyperactivity Disorder (AD/HD) Traumatic Brain Injury Learning Disability I believe I have an undiagnosed condition, and would like to be pre-screened for Learning Disability or Attention Deficit/ Hyperactivity Disorder (LD or AD/HD). If so, skip to Section VII and also complete Section VIII for important questions required before pre-screening can be scheduled. How does your disability impact you academically? How does your disability affect you in your everyday life and daily activities? 3

Only complete the sections below that apply to your disability(ies). After you have completed the appropriate section, move on to Section V. Part A Learning disability, AD/HD, and psychiatric Part C Chronic health condition, and physical or disabilities other mobility disabilities Part B Hard of hearing or Deaf Part D Visual disability or blind A. To be completed only by individuals with a learning disability, attention deficit/hyperactive disorder, or psychiatric condition: Nature of disability (specify type(s)): Date of diagnosis: List the difficulties you experience related to your disability (i.e. reading, writing, concentration, memory, time management, note-taking, etc): B. To be completed only by individuals with a hearing disability or who are Deaf: Do you wear hearing aids or cochlear implants? YES NO If yes, check all that apply: Behind-the-ear hearing aids Do they have Direct Audio Input (DAI)? YES In-the-ear hearing aids In-the-canal hearing aids Cochlear implant ear level processor NO Cochlear implant body worn processor My device has telecoils Have you used a neckloop with telecoils? YES NO My device has a M-T (microphone-telecoil) switch Do you or have you used an FM system/assistive listening device in the past? YES NO If yes, please specify type (brand, model): If yes, how does/did sound get to your ear?: neckloop cochlear implant Please describe how you use a telephone: I use an amplified telephone I use a TTY only What types of other auxiliary aids have you used, if any?: Do you use captioned media? Yes No earphone (in the ear) headphone (over the ear) I use a smart phone for emailing and texting What means of expression and receptive communication do you use? (check all that apply) Oral Communication Speech Reading American Sign Language Signing Exact English Speech-to-text transcription (e.g. CART, C-Print) - Please specify your preferred type: Other (specify): 4

C. To be completed only by individuals with a chronic health condition, or physical or other mobility disability: Which, if any, of the following mobility aids do you use? Prosthesis (specify): Braces Crutches Cane Manual Wheelchair Motorized wheelchair/scooter Other (specify): Do you use stairs? (If so, specify general number tolerable): Do you experience any of the following? (check all that apply) I have difficulty standing for long periods of time. I tire easily when I walk distances. I have difficulty walking up/down stairs. I have difficulty taking notes in class. I have difficulty writing. I utilize assistive technology. I have academic difficulties. Please describe: D. To be completed only by individuals with a visual disability or who are blind: Visual Acuity (if applicable): Right Eye: Left Eye: Degree of Blindness: Total Light Perception Form Perception Travel Aids: Cane Service Animal Do you use Assistive Technology? (Specify type(s)): Do you use alternate format reading materials? YES NO If yes, select from the following: Large Print Specify font size and type (e.g. 20 pt bold, sans serif font): If you use printed large print, specify whether it is used for visual subjects only (e.g. math, science, art) or for all subjects: Electronic Format Specify file type (e.g. Word, DAISY, audio file, accessible PDF): Braille VI. Disability Documentation Please provide information about the documentation of your disability you will be submitting to our office: Name of Provider Providing Documentation: Date of Documentation (month/year): Type of Documentation: Learning Disability, AD/HD, Psycho-Educational, or Neuropsychological Evaluation Letter from previous school confirming approved disability accommodations Disability Verification Form (available on DS website) Letter from Medical Provider 5

VII. Accommodations and Services Please specify what accommodations you are requesting. Disability Services will consider your request in light of your disability as described in your documentation, and other information provided to Disability Services, as well as the requirements of your specific academic program. Testing Accommodations: Extended time for in-class exams and quizzes Amount Requested: Smaller proctored environment Scribe for exams (answer recorded/written for student) Use of computer for exams Stop the clock rest breaks (indicated rest time needed per hour: min per hour of exam time) Accommodations on the General Studies Admissions Exam (GSAE) or other placement/waiver exams (for any Columbia school) Specify Exam(s): Specify Accommodations (if different from above): Other Testing Accommodation: Classroom Accommodations: Note-taking Services Permission to use laptop for note-taking in class Permission to tape record lectures Accessible classroom and furniture Specify your need: Other Classroom Accommodations: Communication/Technology Accommodations: Sign-language interpreters Assistive listening devices (e.g. FM or Infrared systems) Real time captioning (CART) Captioned videos, podcasts, or other media Assistive Technology Specify type: Textbooks in alternate format o Electronic Text- Word Format o Electronic Text- Structured PDF o Large Print (Specify font size and style: ) o DAISY Files o Other: Campus Accommodations: Elevator and lift access Specify location(s): Locker on campus Specify location: Orientation and Mobility Training Accommodations for campus visit Date of visit: Specify accommodations: Other Accommodations: Foreign Language Substitution Note: You must complete the Request for Foreign Language Substitution form (http://health.columbia.edu/files/healthservices/pdf/ods_foreignlanguagesubstitutionform10-11a.pdf) Other Accommodation(s) Specify: I am not requesting accommodations at this time but would like to register given the changing nature of my disability I m not sure what I need I d like to discuss this with someone 6

Remember: It may take up to 3 weeks to review your request, once this registration form AND disability documentation is received. Do you wish to be added to the DS listserv for announcements regarding seminars, workshops, events, and news? (Note: you may not opt out of email communications regarding accommodations, policies, and procedures.) YES NO In case of an emergency, whom may we contact on your behalf? Name: Phone: Relationship: I would like to schedule a meeting or conference call with a Disability Services Coordinator before my request is reviewed Student Signature Date 7

VIII. Information for Students Not Diagnosed With A Disability Name: UNI: Phone # (Preferred): Today s Date: Please take the time to answer the questions below so that the appropriate Coordinator can follow up with you to schedule a prescreening for Learning Disability (LD) and Attention Deficit/Hyperactivity Disorder (ADHD) and/or to understand the difficulties you are experiencing more fully. Note that Disability Services does not release their referral list for evaluators of LD/ADHD without meeting with a student first to complete a pre-screening process. Please explain in greater detail how you were referred to Disability Services, and for what reason: What is your most significant academic concern? Have you experienced a negative impact on your academic performance or personal well-being as a result? If so, please describe. How long have you been experiencing this concern? Have you experienced this concern previously at another point, as far back as elementary school? If so, please specify. 8

Have you tried any strategies on your own to help with the difficulty you re having (e.g. reading notes into a recorder and playing them back so you can listen to them)? If so, please specify. Have you seen a medical provider or mental health counselor regarding your concerns? YES NO If yes, please indicate the following: Morningside student Medical Services Morningside Counseling and Psychological Services (CPS) CUMC Medical Services CUMC student Mental Health Service Private/Off-Campus Provider Are you still working with the provider you have indicated above? YES NO If yes, please indicate dates and outcome of treatment: What are you hoping Disability Services will be able to provide in order to address your concerns? Work with a Learning Specialist to develop study skills, time management strategies, or note-taking skills Exam Accommodations Note-taking Services Other Accommodations Please specify: Referral list to update my learning disability or AD/HD evaluation Referral list for evaluators to complete an initial evaluation of LD/ADHD Explore my academic difficulties to better understand their cause 9