Accessibility Services - Disability Service Office Intake Interview Form

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Office of Accessibility Resources: Disability Services Office Intake Interview Form

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone Number:

OCC Email Address:

Student ID #

Social Security Number

Student Status

What semester did you first attend OCC?

Are you re-admitting?

Have you applied for Financial Aid?

Have you transferred from another college?

What's your major/program of study?

Who is your OCC advisor?

Are you registered in any of these programs? Check a box next to all that apply.

VESID

CBVID

VAVR

If you are registered with VESID, CBVID, or VAVR, please list the name and telephone number of your counselor

List the name of the last high school you attended, along with dates of attendance.

High School name:

Dates of attendance:

Are you a high school graduate, do you have your GED, or are you a member of the Ability to Benefit Program? (Please select one)

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?

Did someone help you fill out this form?

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