OFFICE OF ACCESSIBILITY SERVICES
Division of Student Affairs
Accessibility Form Application
Personal Information
First Name
*
MI
Last Name
*
Date Of Birth
*
- Select Month -
January
February
March
April
May
June
July
August
September
October
November
December
- Select Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Select Year -
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
Emplid
*
Gender
*
- Gender -
Male
Female
Transgender
Other
Other Gender
*
How do you travel to campus?
(Check all that apply)
Access-A-Ride
MTA: Bus/Subway
Walk
Other
Please type other transportation method
Are you registered to vote?
*
Yes
No
Contact Information
Your Address
(Street Name)
*
Apartment Number
Zip Code
*
City
*
State
*
- State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Phone #
Your John Jay User Name
*
@jjay.cuny.edu
Alternative Email address
Emergency Contact Name
*
Emergency Contact Phone
*
Can automated texting service contact you?
*
Yes
No
Cell Phone Number for appointment reminders
How You Got To Know Us
Who referred you to the Office of Accessibility Services?
Agency Sponsorship
(Check all that apply)
ACCES-VR
CBVH
SEEK
VA
Other
Please provide ACCES-VR, CBVH, SEEK, VA or OTHER counselor name & contact information
Are you a CUNY Leads student?
Yes
No
Veteran Information
Are you a dependent of a veteran?
Yes
No
Have you ever been enlisted in any branch of the US military
(Active Duty, Veteran, National Guard, or Reserve)
?
Yes
No
Did your military service include traumatic or highly stressful experiences, which continue to affect you?
Yes
No
Yes (please describe below or attach a documented report):
Click to attach supporting document
Allowed file types word and pdf documents
Enrollment/Academic Status
Registration Status
*
- Select Registration Status -
Full Time
Part Time
Non-Matriculated
Continuing Education
Major
*
Current GPA
*
Are you an Undergraduate?
Yes
No
Please select your undergraduate Level:(e.g Senior,Sophomore)
- Select Undergraduate Level -
Freshman
Sophomore
Junior
Senior
Are you a Transfer Student?
Yes
No
Please type your transfer Institution Name
Degree Type
*
- Select Degree Type -
BA
BS
BA/MA
MA
Certificate Program
Number Of Credits Completed
Disability-related Information
Please answer the following questions regarding your disability and how it impacts your ability to learn and participate in college life
Please indicate your disability type(s)
(Check all that apply)
Learning Disability
Attention Deficit/Hyperactivity Disorder (AD/HD)
Autism/Aspergers
Physical Disability
(Please specify)
Please Specify Below
Chronic Medical Condition
(Please specify)
Please Specify Below
Psychiatric Disability
(Please specify)
Please Specify Below
Visual Impairment/Blindness
Deaf/Hearing Impaired
Temporary Injury/Condition
(Please specify)
Please Specify Below
I use a wheelchair
I use an assistive mobility device
(Please specify)
Please Specify Below
I wear a hearing aid
I have a cochlear implant
I rely on sign language interpreting services and I read lips
I rely solely on sign language interpreting services
I tire easily when walking
I have a need to utilize assistive technology
(Please specify)
Please Specify Below
Other
(Please specify)
Please Specify Below
I have difficulty
reading the blackboard
taking notes in class
writing
standing for long periods of time
walking up/down stairs
I have a need to utilize assistive technology
(Please specify)
Please Specify Below
sitting for long periods of time
Disability Status
Do you have a diagnosed and documented disability?
*
Yes
No
Do you have multiple disabilities?
Yes
No
If yes, please check all that apply
ORTHOPEDIC
Wheelchair user
Other assistive devices (braces, crutches. cane,prosthesis, etc.)
Other orthopedic (no devices)
Other mobility limitation (includes asthma, heart, kidney,CP, spinal surgery)
Hand dysfunction
VISUAL
Totally Blind
Legally Blind
Visually Impaired
Visually impaired (NOT legally blind)
HEARING
Deaf
Hard Of hearing
Other
If you checked other, please specify
Please specify any disability or condition you may have if not listed above
Do you have a medical doctor or physician?
Yes
No
Please provide the physician's contact information
Physician Name
Physician Phone
Do you have a therapist/psychiatrist?
Yes
No
Please provide the therapist's contact information
Therapist Name
Physician Phone
Are you currently taking any medications to treat any disability or medical condition indicated above?
Yes
No
If yes please specify below
Assistive Technology & Alternative Textbooks
What assistive technology/software/textbook formats do you use?
(Check all that apply)
None
Read & Write Gold JAWS
Zoom Text
Kurzweil 1000
Kurzweil 3000
Dragon Naturally Speaking
Other
CCTV
Victor Reader
Handheld Magnifier
Handheld/Portable CCTV
Tape Recorder
Large Print Keyboard
Livescribe Smartpen
Microsoft Word (E-text)
Adobe Acrobat PDF (E-text)
Learning Ally (DAISY Audio, EBook)
Large Print
Requesting Accommodation For the Classes Below
Please click "Click To Add Another Course" below to include all the classes that you want accommodation for.
Course Code
Section
Day(s)/Time
Instructor
Room #
Action
Course Code
Course Section
Day(s)/Time
Instructor
Room Number
Click To Add Another Course
Please make sure to answer the capture below before submitting your application. Thank You.
Your Application is been submitted to the Office of Accessibility Services.