Institutional Equity and Compliance

Disability Disclosure Form

Full Name  



Disability Status:

A disabled person is anyone who: (1) has a physical or mental impairment which substantially limits one or more of the major life activities; (2) has a record of such impairment; (3) is regarded as having such an impairment.

Please check beside any disability which applies to your situation.

Upper & Lower Extremities, e.g., amputation, finger disability
Hearing Impaired
Speech Impaired
Respiratory, except Asthma
Widespread Paralysis or Muscular Dysfunction, e.g., multiple sclerosis, paraplegia, cerebral palsy, epilepsy, Parkinson's disease.
Neuropsychiatric, e.g. personality disorder, head injuries, alcoholism and drug addiction (Rehabilitated Drug User only)
Retardation, e.g., mentally impaired
Trunk, Spine & Abdominal defects e.g., hernia, disk, spinal fusion
Vision impaired
Skin, Cosmetic & Allergy conditions, e.g., facial disfigurement, asthma, allergic dermatitis, skin disease
Generalized or Systemic Diseases, e.g., diabetes, arthritis, leukemia, cancer, diseases of the blood
Gastrointestinal, e.g., ulcer, colitis, colostomy paraplegia, cerebral palsy, epilepsy, Parkinson's disease
Other disabilities, please explain below.