Fillable Disability Support Services (DSS) Accommodation Application (Cascadia Community College)

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Disability Support Services (DSS) Accommodation Application (Cascadia Community College)

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The Disability Support Services (DSS) Accommodation Application (Cascadia Community College) form is 2 pages long and contains:

  • 1 signature
  • 67 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

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CASCADIA
COLLEGE
DISABILITY
SUPPORT
SERVICES
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425.352.8128 disabilities@cascadia.edu
http://www.cascadia.edu/advising/disability.aspx
Disability Support Services (DSS) Accommodation Application
Student Information
Full Name:
Student ID# (SID):
Today’s Date:
Date of Birth:
Home Address:
City:
State:
Zip Code:
Phone Number:
Email Address:
Diagnosis Information
Sensory
Hearing Loss
Deaf
Vision Loss
Blind
Sensory Processing Issues
Other:
Date of Diagnosis:
Learning
Specific Learning Disability
Dyslexia
Dysgraphia
Dyscalculia
ADD or ADHD
Other:
Date of Diagnosis:
Speech or Language
Apraxia
Aphasia
Dysarthria
Other:
Date of Diagnosis:
Psychological/Emotional
Anxiety Disorder
Bipolar Disorder
Mood Disorder
Post-Traumatic Stress Disorder
Schizophrenia
Other:
Date of Diagnosis:
Mobility
Cerebral Palsy
Spinal Cord Injury
Paraplegic
Quadriplegic
Multiple Sclerosis
Other:
Date of Diagnosis:
Neurological
Autism Spectrum Disorder (ASD)
Traumatic Brain Injury (TBI)
Seizure Disorder
Tourette’s
Other:
Date of Diagnosis:
Chronic or Acute Conditions
Cancer
Fibromyalgia
Immune Disorder
Environmental Illness
Crohn’s Disease
Date of Diagnosis:
Diabetes
Chronic Fatigue Syndrome
Cardiac/Cardiovascular
Asthma or Pulmonary
Other:
Other, please describe:
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Present Challenges Due to your Disability/Diagnosis
Attention/Concentration
Organization
Time management
Emotional/Feelings management
Class participation
Group participation
Social interaction
Energy levels/Endurance
Chemical sensitivity or allergy
Environmental issues (e.g. temperature, lighting,
sounds)? Please describe:
What classroom accommodations have you had in the
past, if any?
General Questions and Other Information
Currently taking medications that we should be aware
of? If applicable, please list medications:
What are the side effects of your medication?
Mark all that apply to you, if any:
Veteran
Running Start student
Adult Basic Education (ABE) student
English Language Program (ELP) student
Client of Division of Vocational Rehabilitation (DVR)
Receive services from Department of Social Health &
Services (DSHS)
Do you wish to be placed on the Emergency Assistance List
in case of a campus emergency? Yes No
If YES, please initial below to release permission for DSS to place
your name and contact information on a list so that staff will do
what they can to assist you appropriately.
Student Initials:
I understand that students who receive reasonable accommodations for disability must meet essential academic and
conduct standards. Cascadia College’s academic and conduct standards can be found online.
I am aware that my rights and responsibilities are outlined in the DSS Handbook on Cascadia’s website.
I understand that it is my responsibility to discuss questions or concerns I have regarding accommodations.
I give DSS permission to discuss this information, my accommodations, and other relevant information with faculty,
advisors, administrators, and/or staff to further my educational goals. I understand DSS will enter my disability
status in Student Success Services records for confidential statistical purposes.
X
Stu d en t Sig n a tu re a n d Date
Cascadia College is an equal opportunity institution and does not discriminate on the basis of race, color, religion, gender and/or sex, disability, national origin, citizenship status,
age, sexual orientation, veteran’s status, or genetic information. All Cascadia materials are available in alternative formats and can be requested by contacting the Human Resources
office.
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Disability Support Services (DSS) Accommodation Application (Cascadia Community College)

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Completed 8 October 2020

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