Gallaudet University
The Center of Academic Programs and Student Services (CAPSS)

CAPSS > Office for Students with Disabilities > Forms

Intake Form

Print a hard copy and submit by mail, fax or in person.

Date:

Staff name:

Referred by:

     

Student  Information

name: last

first

middle

male 

female

  

social security number

birth date

gallaudet identification number

e-mail

phone number

campus mail po box

name of dorm

   

address (if off campus):

city

state   zip code

   

are you a united states citizen? yes no
if "no", what is your visa status? f1  j1  b1  b2
have you used oswd services before? yes  no
if "yes" - when?

Education

name of high school / state

type of high school attended

residential  public  day program   other

type of school

name of school and state

dates attended
to  | from

degree

major

gpa

(example) college

university of maryland, md

1990 - 1993

ba

business

4.0

Please respond to all questions by checking all items that apply to your situation

Demographic Data:

class

race/ethnic group

or other

Communication Mode:

asl

pse

finger spelling  

home signs/gestures

lip reading

oral

residual hearing

signed english

tactile sign  

tracking sign

voice and sign  

other

Financial Support

grant

loan

college work study

scholarship

stipend

vr

ssi/ssdi

parents

part-time employment

full-time employment

veterans

other

Type of Disability

hearing impairment

visual impairment

cardiovascular disorder

diabetes

epilepsy

learning disabilities

menieres diseases

arthritis

multiple sclerosis

spinal cord injury

burns

cancers

amputations

stroke/cerebral trauma

pulmonary dysfunctional

aids/hiv

other

Medical Diagnosis - Hearing Impairment

etiology (how?) or other

degree of impairment - db hearing loss left right

Medical Diagnosis - Visual Impairment

etiology (how?) or other

age of onset degree of impairment

Medical diagnosis - Other impairments

etiology (how?) or other

age of onset degree of impairment

Assistive Devices

wheelchair

hearing aid

cane

guide dog

walker

crutches

braces

glasses

braille

telebraille

perkins brailler

dp-11 large print computer

closed circuit television

vista

enlarged print

magnified devices

other

Treatments

medications

month

year

                                          

surgical

month

year

 

 

 

occupational therapy

physical therapy

psychosocial treatment

orientation / mobility  instruction

communication therapy

self-care training

Please answer the following questions:

A I am a disabled student who has learning and performance strengths in these areas (list your abilities):

B. My disabilities effect my ability to (list things you are not able to do independently):

C. To compensate for these disabilities, I do the following:

Thank You.

For more information or assistance, contact:

Center for Academic Programs and Student Services (CAPSS)
Gallaudet University   Office for Students With Disabilities
Student Academic Center Room 1022
800 Florida Ave. NE
Washington, D.C.20002-3659
(202) 651-5256 (v/TTY)
oswd@gallaudet.edu