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ASSIGNMENTS QUESTIONNAIRE
For New Residents with Physical Disabilities

General Information
Name (Last)
Name (First)
Phone ( )    -

This questionnaire will be used to help the Residence Services Office determine the best
housing assignment for you.

  • Please provide a brief description of your physical disability.
  • Do you use a wheelchair or scooter daily?

Yes No

  • Width of wheelchair or scooter in inches
  • How many wheelchairs or scooters will you bring?
  • Please list quantity and type you will bring

  • Can you lock/unlock a standard deadbolt using a key?

Yes No

  • What special large equipment will you bring (hospital bed, lift, etc.)
  • Will you or your equipment require more space than what is commonly allotted in
    a residence hall space?

 

 


Yes No
Comments

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Last updated: Thu. Dec-08-11, 12:57
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