Location: VC 2-272
Phone: 646-312-4590
Email:
INTERVIEW FORM
For use with a Screen Reader.
STUDENT INFORMATION
CUNYFirst ID#:
Date:
School(Indicate your school by marking “yes” next to it.)
Zicklin School of Business
Weissman School of Arts & Sciences
Marxe School of Public & International Affairs
Please indicate “yes” next to the following:
Undergraduate
Graduate Program
Freshman
Transfer
Your Name:
Mailing Address:
Cell Number:
Ethnicity:
Date of Birth:
Email Address:
Indicate your gender by marking “yes” next to one of the options below.
Male
Female
Transgender
Prefer not to answer
How did you find out about Student Disability Services?
What is your disability?
Is your disability temporary?
EDUCATION
High School:
College:
Did you have an IEP in High School?
Are you the first person in your household to attend college? (Underline your answer.)
Yes
No
I don’t know
WORK HISTORY
Are you currently working?
Career Goals: Are you interested in discussing employment opportunities and career-development options with a CUNY LEADS Advisor?
Please share (if you wish) whether or not you are associated with any of the following by indicating “yes.”
New York State ACCES/VR
CBVH (Commission for the Blind and Visually Handicapped)
Veterans Benefits and Services
Other
The following is a list of some MAJOR life activities.
Place “yes” next to each activity you believe is affected by your disability.
Writing
Calculating
Concentrating
Listening
Memorizing
Reading
Lifting and Carrying
Performing Manual Tasks
Sitting
Walking/standing
Spelling
Talking
Breathing
Eating
Hearing
Seeing
Sleeping
Other
Do you take medication that relates to your disability?
Are there side effects from this medication that may affect your classroom performance?
Do you currently use any of the following assistive devices or assistive technology? Indicate your answer by marking “yes” next to all that apply.
Wheelchair
Cane
Screen Reader
Tablet
I communicate by sign language
LiveScribe Recording Pen
Digital Recorder
FM Unit
Speech Recognition Software
MAC Computer
Hearing Aids
Other
What accommodations are you requesting at Baruch College?
When this application is complete, and you have provided documentation of your disability, a counselor will schedule an interview with you to review your Accommodation Request. During that interview your accommodations will be written and you will be asked to sign the following statement:
I understood the questions on this application and have answered them truthfully. The accommodations offered to me in this setting, or the reasons I am not receiving accommodations in this setting, have been clearly explained to me. I provided documentation of my disability and my original documents were returned to me. I understand that Student Disability Services will not contact my professor to inform them that I am registered with this office. It is my responsibility to do so. If an issue arises that relates to accommodations in the classroom, I should contact this office for assistance.
Student’s signature:
Counselor’s signature:
Date:
This office is a National Voter Registration Site.
If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Underline your answer.)
Yes
No
No, already registered
If you would like help in filling out the voter registration form, this office will assist you. You may fill out the application in private. Deciding whether or not to register to vote is up to you, and will not affect the services you receive from this office.