Last Name:
First Name:
Middle Name:
Permanent Address:
City:
State: Zip Code:
Phone Number:
Sex: Female Male
Date of Birth: Month: Day: Year:
1. I take care of personal responsibilities.
Yes No a. I get up in the morning on my own. Yes No
Yes No
a. I get up in the morning on my own.
b. I leave enough time for personal hygieve, dressing and breakfast each morning.
c. I remember the appropriate things I need for the day (keys, books, supplies, money).
d. I get to school or work on time.
e. I keep scheduled appointments.
2. I am organized
a. I complete daily assignments on time.
b. I plan steps for a project.
c. I start a project on time.
d. I complete a project on time.
3. I have good study skills.
a. I know the best study environment for me.
b. I know what to review for a test.
c. I get better grades when I study.
d. I use books, lecture notes, peers, and other sources when I study.
e. I study with other people (i.e., students, groups or teachers).
4. I use my time wisely and efficiently.
a. I know how much time I will need to spend daily on coursework.
b. I know how long I should allow for daily studying.
c. I know how much time I need to allow for advocacy issues.
5. I know the best work environment for me to be successful.
a. I know the time needed to get ready for a task.
b. I know the time needed to learn new skills.
c. I am comfortable asking for advice.
d. I know how to get along with coworkers.
2e. I am able to accurately predict the time it will take to complete a project/assignment. Yes No 2f. I use a calendar to keep track of assignments/appointments.
2e. I am able to accurately predict the time it will take to complete a project/assignment.
2f. I use a calendar to keep track of assignments/appointments.
6. I can physically complete the process of reading.
a. I see standard print.
b. I can hold the book.
c. I can turn the pages.
d. I can recognize words when I see them.
e. I can sound out or decode unfamiliar words.
7. I understand what I read.
a. I understand information in print the first time I read it.
b. I use different strategies for different types of reading.
c. I summarize after I read.
d. I find main ideas when I read.
e. I pick out important supporting details.
f. I skim for a general overview.
g. I scan for key words and vocabulary.
8. I remember what I read.
a. I recognize information I have read when it appears in another way.
b. I remember information I have read.
9. I apply what I have read.
a. I convert what I have read into my own words.
b. I read for pleasure. (If you answer yes, what do you read?)
c. I integrate new information with what I already know.
d. I demonstrate my knowledge on tests that require reading (i.e., SAT, achievement tests).
Supplementary Questions for Reading
7h. I ask myself questions as I read.
10. I take good notes from a lecture.
a. I can physically hear the speaker.
b. I understand what I hear.
c. I shut out distractions.
d. I stay focused for a class period.
e. I am able to write while I listen.
f. I write fast enough to keep up with the lecturer.
g. I copy notes accurately from an overhead or the board.
h. I know various notetaking methods that will work for me.
11. I use my notes effectively.
a. I pick out the important points.
b. I use my notes to learn the necessary material.
c. I organize my notes in a useful way.
d. I organize my notes in a way that matches my learning style.
e. I schedule time to review class notes as soon as possible after class.
12. I take effective notes from a textbook.
Yes No a. I use headings effectively. Yes No
a. I use headings effectively.
b. I recognize what is important.
c. I take enough notes to be useful, not too much or too little.
Supplementary Questions for Notetaking
10i. I know how to condense and/or summarize what the instructor is saying so i can get it down in useable note form. Yes No
10i. I know how to condense and/or summarize what the instructor is saying so i can get it down in useable note form.
Change of directions. Read each numbered statement and select a response to all of the lettered statements below it.
13. I demonstrate my knowledge best in the following formats.
a. Multiple choice test Yes No
b. True/False test Yes No
c. Essay Yes No
d. Fill in the blank Yes No
e. Oral – tell answers aloud Yes No
f. Written report Yes No
g. Project Yes No
h. Portfolio (compilation of work samples) Yes No
a. Time modification Yes No
b. Reader Yes No
c. Alternative site (i.e., lights, sound, furniture) Yes No
d. Scribe (person who writes answers from dictation) Yes No
e. Alternative test format (i.e., Braille, multiple choice, etc.) Yes No
f. Use of assistive devices (i.e., computer, calculator, spell checker, tape recorder) Yes No
15. I have the following evidence or documentation that states that I am eligible for these accommodations (Psychological report, doctor’s letter, other testing).
Directions 1. Read each numbered statement. 2. Mark your answer and in the space provided explain how you accomplish the task. 3. If you answer the numbered statement "No", please be sure to answer the lettered statements below it.
16. I can write legibly.
a. I can physically use a pen/pencil.
b. I write so others can read my writing.
c. I use a keyboard efficiently.
17. I communicate my ideas in writing.
a. I think of ideas to write about.
b. I remember my ideas.
c. I organize my ideas.
d. I write what I am thinking.
18. I produce papers that others (teachers/supervisors) consider acceptable.
a. I use my notes when writing a paper.
b. I edit my own work.
c. I write with standard English sentences.
d. I write using correct grammar.
e. I write using proper spelling.
f. I can write a research paper.
19. I use a word processor (rather than a computer).
a. I can keyboard (type) efficiently.
b. I can write a paper using a word processor.
20. I use a PC (personal computer).
a. I am fluent using the following software:
21. I use a computer to check my spelling and grammar.
a. I use a hand held spell checker.
b. I add frequently used words to my spell check program.
c. I have found software that helps me locate the words I am trying to use.
d. I use the read aloud function on my machine.
22. I know that the equipment/software that I use at home is compatible with what is available on campus or at work.
Yes No Please explain your answer:
Please explain your answer:
23. I understand myself and how I learn.
a. I know the kind of environment in which I learn best.
b. I know how to learn material when the teacher’s style is different from my own.
24. I can effectively communicate.
a. I seek help when I need it.
b. I am assertive (not passive or aggressive).
c. I can communicate my ideas.
d. I can start and end conversations effectively.
e. I can express my feelings appropriately during a conversation.
f. I understand body language and facial expression (my own and others).
g. I listen attentively in conversations.
h. I am aware of and respect personal space.
i. I can effectively listen and communicate to help resolve conflicts in a disagreement.
j. I know how to contact the support service people affiliated with the college/workplace I am entering.
25. I am confident in my ability to be successful.
a. I can apply my life experiences to the classroom/training situation or workplace.
b. I can identify my goal for being in school or in training.
c. I am comfortable with people of other ages, races, religions and social classes.
26. I take responsibility for self advocacy on a college campus.
a. I schedule a meeting with the support service provider before each semester.
b. I schedule a meeting with each instructor to request my accommodations.
c. I arrange for testing accommodations in a timely fashion.
d. I take responsibility for obtaining services (i.e., notetaking) and supportive material (tapes, notes, etc.)
27. I manage my money.
a. I follow a monthly plan.
b. I have a checking and savings account.
c. I balance my checkbook.
28. I arrange for transportation.
a. I use public transportation.
b. I drive.
c. I take responsibility for car maintenance and insurance.
29. I do my laundry independently.
a. I do my laundry at home.
b. I use coin-operated machines.
30. I handle my own medication appropriately and safely.
31. I know when, where and how to get help if I am sick or injured.
32. I take care of my health needs.
a. I know my health insurance number and coverage.
b. I know my doctor’s name and phone number, etc.
c. I prepare nutritious meals.
d. I am aware of foods that affect my ability to function.
e. I get enough rest.
f. I exercise regularly.
g. I have strategies to handle stress.
33. I have accepted my disability.
a. I still don’t think I have a disability.
b. I blame others for this problem.
c. I am angry about having this problem.
d. I often feel sorry for myself because of this disability.
e. I have difficulty understanding exactly what my diagnosis means and I need more information.
g. I understand my diagnosis but I have not developed adequate strategies to compensate.
34. I know how my disability impacts me as a learner.
a. I understand how it impacts my reading level.
b. I understand how I need to have more time to accomplish new learnings.
c. I understand how it impacts my need to understand information in a different way.
d. I still have questions about how to compensate for this disability.
35. I know how this disability affects my ability to handle stress.
a. I use relaxation techniques.
b. I take out my anger and/or frustration on others.
c. I use my support network to vent in a healthy way.
d. I have a good relationship with a clergy, a doctor or a therapist.
Easy and Hard Please respond to the following questions.
36. When I work, the easiest tasks or jobs are:
37. The hardest task for me to do when I work is:
38. My favorite kind of learning is:
39. My least favorite kind of learning is: