Skip to Main Content

The University of Tennessee

Office of Disability Services

Frequently Used Tools:



Student Intake Form


Student Intake Form

In order to establish eligibility for services and to enable our staff to work more effectively with you in the provision of services, please complete this form and provide documentation of the disability as outlined by our Documentation Guidelines. All records will remain strictly confidential and are not a part of your academic record.

The aforementioned guidelines are provided so that Disability Services can respond appropriately to the individual needs of the student. We reserve the right to determine eligibility for services and modifications to programs based on the quality of the submitted documentation. All documentation is confidential.

Confidentiality

All information provided to Disability Services is confidential. Only with the written consent of the student will information be provided to appropriate offices when information has been deemed necessary to support the individual's educational and professional pursuits. We will make every effort to include the student and/or inform the student about any conversations related to them. Specific information (including documentation) relating to the student's disability will not be given out without written permission from the student.

By initialing in the box below you are stating that you understand the above policy and agree with the terms.

Initials

It is strongly recommended that all forms and documentation be returned to our office before the start of the semester in order to allow time for processing.

If you have a temporary disability, or injury please fill out the Temporary Intake Form instead of this form.

* Required field

Biographical Information
Date: *
Email: *
Student Number: *
First Name: *
 Last Name: *
Gender: *
 Birth Date: *
Current Address Permanent Address
Phone: *
 Phone: *
Address: *
 Address: *
City: *
 City: *
State: *
 State: *
Zip: *
 Zip: *
Major:
Current Year in School
First Semester at UT
 Year: 		Anticipated Graduation Date:
Year:

Disability Information
Primary Disability: *
 Age at Diagnosis: *
Other Diagnosis:
Age at Diagnosis:
Other Diagnosis:
Age at Diagnosis:
Other Diagnosis:
Age at Diagnosis:
Please list any Disability medications you are currently taking:
Name:
 Amount:
 Times per day:
Name:
 Amount:
 Times per day:
Name:
 Amount:
 Times per day:
Name:
 Amount:
 Times per day:

If known, please describe the cause of your disability (i.e. birth trauma, accident, degenerative):

Functional Limitations: Please select the extent to which you believe your diagnosed condition affects the following major life activities.

Activity
None
Undetermined
Mild
Substantial
Caring for oneself
Talking
Hearing
Breathing
Seeing
Walking/Standing
Lifting/Carrying
Sitting
Performing Manual Tasks
Eating
Working
Learning
Reading
Writing/Spelling
Calculating
Memorizing
Concentrating
Listening

In your own words, please describe how your disability impacts your daily life and education:

How do you cope with the limitations of your disability:

Please share any other information that you feel would be helpful to ODS:

Service History

If your were diagnosed prior to age 18, please tell us about your high school experience:

What was the enrollment of your school:
 What type of school did you attend:
Public Private
Did it have a disability support program?
Yes No 		Did you receive support services?
Yes No
Please list all academic accommodations and services you received:
If you have attended a college or university prior to UT, please provide the following information:
School Name:
 City and State:
Dates Attended:
 Reason for leaving:
Please list all academic accommodations and services you received:
Please list the academic accommodation(s) that you think you will use through ODS (see brochure for a description of what is available)
Please select alternative formats you have used in the past:
None Books on Tape
Large Print Scanned Books
Braille
 
Have you used any assistive technology in the past? Yes No
If yes, please select from list below:
Speech input software FM Systems
Voice Output Software Screen Enlargement Software
Braille N' Speak Other:
Check this box if you would like to learn more about which if any assistive technologies are available to you and how they can aid in your education.
Other:
  
Name of Counselor:
 Phone:
Address:
 City:
State:
Zip:

Please check any other program or state agency from which you receive financial assistance:

SSI/SSDI
Yes No 		Services for the Blind
Yes No
Other:
  

Please check any of the services below that you have received in the past in the "Previously Received" column. Please check the services that you are interested in requesting at UT in the "Requesting at UT" column.

Support Services and Accommodations

Previously Received

Requesting at UT
Test Accommodations (Please List)
Assistance with Note taking (Please Describe)

Document Conversion


    
» Audio Format
» Enlarged Text
» Braille
     

Audio Equipment


    
» Tape Player
» Disc Player
» Magnification Software
» Screen Reading Software
» Speech Input Software
» Other
     
Sign Language Interpreting
Transcribing (CART, C-PRINT, TYPEWELL)
Assistive Listening Device
     
Physical Access Assistance (Please Describe)
     
Housing Accommodations (Please Describe)
     
Transportation/Parking Assistance (Please Describe)
     
Orientation and Mobility Training
Special Education/504 Plan
N/A
Private Tutors or Academic Specialists
N/A
Personal Care Assistance
N/A