New Student Accommodation(s) Request

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The Center for Equal Access Intake

THE COLLEGE OF ST SCHOLASTICA
The Center for Equal Access
1200 Kenwood Ave. Duluth, MN 55811-4199
Email: access@css.edu 

This form is confidential and will only be seen by the professional staff of The Center for Equal Access. For more about confidentiality, please see the Confidentiality Statement below. Please complete the form to your best ability. Your responses will be discussed in further detail with your Access Specialist.

Confidentiality

Confidentiality is of utmost importance in all matters pertaining to students with disabilities. For the full Confidentiality Statement, see The Center for Equal Access Student Handbook.

Please use your CSS issued email address

Please include the date of onset (date it started and was diagnosed).

Do you have a family history of this same or a similar condition?
Please rate, from no impact to severe impact, how your disability limits your life activities in the following areas
ConcentratingRequired






MemoryRequired






SleepingRequired






EatingRequired






Self-careRequired






MobilityRequired






Writing or TypingRequired






ReadingRequired






Managing internal distractionsRequired






Managing external distractionsRequired






Timely submission of assignments or examsRequired






Attending class regularly and on timeRequired






Stress ManagementRequired






OrganizationRequired






HearingRequired






VisionRequired






(stress, work, family/intimate partner problems, illness, homelessness, etc)

Do you take your medication regularly?
Have you used accommodations in the past? This could be an IEP/504 in K12 or at another post-secondary institution.

Referral

Were you referred to The Center for Equal Access? Required
Upload supporting document(s)