Student Information Form

This form helps us understand how you learn best, what challenges you may experience in academic settings, and what supports could help you be successful.
You are not expected to have all the answers—your Student Success Advisor will work with you to identify appropriate supports and accommodations.

You can register with Accessibility Services without a diagnosis. An advisor will work with you to explore your needs and guide you through any documentation requirements.

1. Contact Information

Full Name

College Email Address

Phone Number

Program Name

Campus

2. Skills Reflection

This checklist focuses on how academic tasks and environments work for you.
Please check the statements that reflect your experience most of the time. You may check items across multiple sections.

Reading and Written Materials

I can read and understand course materials without difficulty

I understand what I read but it takes me longer than average

Large amounts of reading feel overwhelming or fatiguing

I need to re read material multiple times to understand it

Dense, technical, or complex language is difficult to process

Online or screen based reading is harder than print (or vice versa)

My first language is not English

Optional Comments:

Writing and Written Expression

Writing is an area of strength for me

I have ideas but struggle to organize them in writing

Starting writing tasks is difficult

Writing takes me significantly longer than expected

Time limited writing (e.g., exams) makes it hard to show what I know

Spelling, grammar, or mechanics interfere with expressing ideas

Typing or handwriting affects my written work

Editing and revising are challenging

Optional Comments:

Attention, Concentration, and Sustained Effort

I can focus for extended periods without difficulty

My attention fluctuates depending on the task or environment

I lose focus during lectures or long classes

Distractions (noise, movement, online notifications) impact my focus

I find it hard to sustain attention during exams

Mental effort leads to fatigue before tasks are completed

Optional Comments:

Organization, Planning, and Time Management (Executive Functioning)

I manage deadlines and assignments effectively

I have difficulty starting tasks, even when I understand them

Long term or multi step assignments are challenging

I underestimate how long tasks will take

Managing multiple courses at once is difficult

I struggle with prioritizing tasks

I rely heavily on external reminders or supports to stay organized

Optional Comments:

Learning, Processing, and Memory

I learn new information at a typical pace

I need extra time to process verbal or written information

I understand concepts during class but forget them later

I have difficulty listening and writing at the same time

I benefit more from visuals, demonstrations, or hands on learning

I remember information better with repetition or structured supports

Optional Comments:

Studying and Exams

My exam performance reflects my understanding of course material

I require more time than peers to study effectively

Exam anxiety interferes with performance

Different exam formats affect my performance (e.g., multiple choice vs. written)

Noise, lighting, or room setup impacts my testing performance

Optional Comments:

3. Strategies That Help You Learn

What strategies have helped you manage learning or academic challenges in the past?

Examples: using a calendar or planner, studying with others, breaking tasks into steps, assistive technology, recording lectures, visual supports.

4. Previous Accommodations or Supports

Have you previously used accommodations or supports in high school or at another college/university?

Yes

Not sure

If yes, please describe which accommodations or supports were most helpful (and any that were not helpful, if applicable)