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This tool is designed for any student seeking acommodations at a postsecondary institution.
Please note that the language used ('difficulty', 'trouble', etc.) are not meant to be pathologizing or persecutive, they are just meant to allow for context within we realize that everyone has different environmental, social, and physical barriers that affect the way they learn and function in the postsecondary environment.
You are not required to answer questions that make you uncomfortable :) Answer honestly to questions you do respond to. Answering 'No' to the bolded questions at the end of each section does not mean you will not recieve any accommodations, they are just an indicator to your advisor to the type of help you need.
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A. Concentration and Memory1. I have difficulty shifting my attention between two thinking tasks (listening and writing, reading and speaking)A. Concentration and Memory
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2. I have trouble double-checking my documents or work for mistakes
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3. I have trouble getting back on track with what I was doing if I get interrupted or distracted
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4. I have to pay extra attention to avoid making mistakes
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5. I have difficulties concentrating on a task for an extended period of time
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6. I have trouble remembering new information (dates, times, words, classroom numbers)
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7. I use written lists in order to not forget things
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8. I have difficulties remembering the names of familiar objects or concepts
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9. I have trouble remembering where I put things
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10. I have difficulties remembering a list of 5 or more items without writing it down
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11. I forget what I meant to do in a room when I walk in (or what I meant to grab from a cupboard/fridge when I open it)
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12. I have trouble remembering the names of people who should be familiar to me
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There are certain times of day where I have less trouble with concentration and memory
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My difficulties with concentration and memory interfere with my ability to do things I enjoy
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B. Organization and Time Management1. I have difficulties accurately following complex instructionsB. Organization and Time Management
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2. I have difficulties learning new tasks or instructions
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3. I have difficulties performing basic arithmetic in my head (double digit addition/subtraction, fraction multiplication/division)
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4. I have to read something multiple times to understand it
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5. I have trouble planning out the steps of tasks
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6. I have trouble making decisions
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7. I have trouble planning for and keeping irregular appointments (medical, office hours, social meetups)
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8. I find it hard to complete my tasks if someone is rushing me
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9. I find it hard to keep track of time (missing the bus, getting to class late)
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10. I have difficulties getting started on tasks that should be simple (weekly classwork, writing an email, booking an appointment)
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11. I feel that my thinking is slower than others’
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12. I react slowly to things that are said/done to me
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My difficulties with organization and time management interfere with my ability to do things I enjoy
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My difficulties with organization and time management interfere with my ability to socialize with friends/family
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C. Stress Management1. I have difficulties calming down during stressful situationsC. Stress Management
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2. I have a racing, pounding heart, and/or difficulty breathing during stressful situations
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3. I get stressed when dealing with uncertainty
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4. I get anxious when my normal routine is disturbed
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5. I am uncomfortable making new relationships
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6. I get anxious speaking in front of many people
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7. I have trouble finding new ways to manage daily activities when old ways don’t work
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8. I am unable or unwilling to express my emotions
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9. I have difficulty moving on when problems arise
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10. I have trouble receiving help from others
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My difficulties with stress management interfere with my ability to socialize with friends/family
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My difficulties with stress management make me feel self-conscious
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D. Participation1. I have difficulties using a computer without assistive technology or other supportD. Participation
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2. I have difficulties using touch-screen devices without support
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3. I have trouble navigating dark rooms or environments
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4. I have trouble getting around in an unfamiliar environment
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5. I have trouble going outside in challenging weather
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6. I have difficulties using public transportation
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7. I am unable to drive a car to my academic environment when I need to (classes, off-campus learning)
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8. I avoid public places or activities, including events I think I could enjoy
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9. I have difficulties carrying bags (groceries, backpacks)
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10. I have trouble performing household chores without support
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11. I have difficulties managing my finances
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12. I have difficulties preparing my own meals
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My difficulties with participation interfere with my ability to do things I enjoy
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My difficulties with participation interfere with my ability to socialize with friends/family
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E. Social Skills1. I feel like the words I want to use are on the ‘tip of my tongue’ in conversationE. Social Skills
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2. I have trouble getting my point across when speaking to someone
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3. I have trouble communicating verbally
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4. I have trouble speaking clearly and/or fluently
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5. I worry about slurring my words or mumbling when I speak
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6. I have trouble maintaining or engaging in conversations
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7. I have difficulties bringing the correct words to mind during conversations or while texting
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8. I feel uncomfortable around large groups of people
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9. I have difficulties communicating in English without technological support (voice-to-text, google translate)
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10. I have difficulty engaging in social activities outside my home
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My difficulties with social skills interfere with my ability to socialize with friends/family
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My difficulties with social skills make me feel self conscious
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F. Health1. I need to use the bathroom frequentlyF. Health
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2. I experience migraines (either from stress, sensory issues, or other illness)
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3. I have trouble taking care of my personal hygiene
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4. I have trouble taking my medication regularly
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5. I have difficulties recognizing risks and taking steps to prevent accidents or injury
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6. I find it difficult to engage in my hobbies or recreational activities
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7. I do not get enough sleep multiple nights in a row
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8. I have trouble falling asleep
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9. I have trouble staying awake during the day
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10. I have difficulties exercising regularly
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My difficulties with health interfere with my ability to do things I enjoy
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There are certain times of day that my difficulties with health affect me less
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G. Physical Ability1. I find it hard to stand or walk for more than 15 minutes (disability, discomfort, pain)G. Physical Ability
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2. I find it hard to sit for 60 minutes or more (discomfort, pain, agitation)
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3. I am unable to climb a flight of stairs, with or without rails
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4. I cannot step up and down curbs
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5. I find it difficult to sit down and sit up from chairs (with or without arms)
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6. I am unable to push open a heavy door
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7. I have difficulties moving on slippery surfaces outdoors
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8. I have trouble writing with a pen or pencil
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9. I have trouble typing on a keyboard
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10. I have difficulties opening small containers or removing wrappings from small objects
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I have strategies that help me cope with my difficulties with physical ability
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My difficulties with physical ability interfere with my ability to do things I enjoy
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H. Sensory Perception1. I am unable to hear clearly, with or without the use of assistive technologyH. Sensory Perception
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2. I am unable to see clearly, even with the use of glasses
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3. I am unable to feel and/or react to painful stimulation
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4. I have difficulty reading for long periods of time due to visual distortions (blurring of words, eyes focusing on spaces between words)
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5. I have difficulty discerning between colours (red/green, blue/yellow, contrast)
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6. I have difficulties staying in brightly lit environments (discomfort, migraines, tiredness, constant squinting)
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7. I have difficulty making out the letters/words on pages
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8. I have issues with strong scents
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9. I have difficulties with loud or high-pitched noises (discomfort, pain, stress, distraction)