OFFICE OF SERVICES FOR STUDENTS WITH SPECIAL NEEDS
ONONDAGA COMMUNITY COLLEGE
DISABILITY SERVICES OFFICE
INTAKE INTERVIEW FORM
Please fill out this form and bring it to your appointment.
Today’s Date: _______________________________
NAME: _________________________________________________________________
ADDRESS: ______________________________________________________________
______________________________________________________________
Telephone: ________________ Cell Phone: _________________
Birth Date: _______________ Email: ______________________________
Note: Please use OCC email
Social Security Number _______________ Student ID Number _________________
Student Status: ____ Full-time ____ Part-time
What semester did you first attend at OCC? _________________ Are you re-admitting? ____ Yes ____ No
Have you applied for financial aid? ____ Yes ____ No
Have you transferred from another college? ____Yes ____ No
What college? __________________________________________
OCC Curriculum/Program of Study: _______________________Advisor: ___________________________
Are you registered with: VESID _____
CBVID _____
VAVR _____
Name & telephone number of Counselor: __________________________________________________
Name and dates of last high school you attended: ____________________________________________
Check one of the following:
____High School Grad or ____GED ____Ability to Benefit Program
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For Official Use Only: ADD BCK BLI DEF EMO HI LD MED NAD OI OTH RMI SUB TBI VI WC
TEMP ___________________________ until _______________________________
Primary Code __________________________
Secondary Code ________________________
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OCC Student Accommodation Request Form
Directions: Students seeking an accommodation of a disability must complete this form and also provide current documentation substantiating the disability. Please provide all of this information to the Disability Services Office (DSO) when you come in for your intake appointment. The Disability Services Specialist will discuss this information, your circumstances, and potential accommodations with you.
Please describe your disability and how it may impact your ability to participate in educational programs and activities at OCC:___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please describe the nature of any treatment for your disability and any medications you currently take:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please describe the accommodation you are seeking._______________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What, if any, assistive equipment or software have you used? ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________ _______________________
Student Signature Date
Did someone else help you fill this out? ____ Yes ____ No
Name: __________________________________ Relationship: ___________________________
Revised 4/6/10
DSO Intake Interview form-Microsoft Word
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