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Temporary Disability Intake

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Temporary Disability Intake Form

Dear Student,
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 Serivces 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.

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.

* Indicates a Required Field

Biographical Information

Date: *
Email: *	Student Number: *
First Name: *	Last Name: *
Gender: * Select Male Female	Birth Date: *
Current Address	Permanent Address
Phone: *	Phone: *
Address: *	Address: *
City: *	City: *
State: * Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	State: * Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: *	Zip: *
Major:	Current Year in School Select Freshman Sophomore Junior Senior Graduate
First Semester at UT Select Fall Spring Summer  Year:	Anticipated Graduation Date: Select Fall Spring Summer Year:

Disability Information

Primary Injury: *	Date of Diagnosis: *
Expected length of Injury: *

Please list any injury related 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:

Please describe the cause of your injury:

Are you able to walk independently? (without crutches or a wheelchair)
Yes No

Are you able to dress yourself?
Yes No

Are you able to write independently?
Yes No

Do you require transportation services?
Yes No

Please list the academic accommodation(s) that you think you will use through ODS (see brochure for a description of what is available)