Appendix

Individual Accommodations Model (I AM)

Student Questionnaire

Background Information

Name: Age:

College:

Gender Please mark.

Female Male

Ethnicity Please mark all that apply.

Hispanic or Latino Not Hispanic or Latino

Race Please mark all that apply.

American Indian or Alaska Native Asian

Black or African American Native Hawaiian or Pacific Islander

White

College Career and Future Plans

Please circle the number of years you have been enrolled in college.

< 1 1 2 3 4 5 Other

How many units/credits are you enrolled in this semester?

How many total college semester units/credits have you earned?

What is your goal for attending this college? Please circle.

AA/AS Degree Vocational Certificate Other

Do you currently receive financial aid? Yes No

Please indicate your anticipated future plans after leaving college.

Education	Work	Other
Other 2-year college	Professional	Please specify:
4 year college	Technical
specialized training	Clerical
Other	Armed forces
Don't know	Other
	Don't know

Did you drop out of school between kindergarten and 12th grade?

Yes No

Did you graduate from high school? Yes No

If no, did you earn a GED diploma? Yes No

Some students finish high school or complete the GED and wait awhile before starting college. Did you finish high school or GED and enroll in college within the same year? Please circle.

Yes (e.g. graduated from high school in May and started college in August)

No (e.g. graduated from high school and waited six or more months before starting college)

Are you a parent? Yes No

If yes, how many children do you have?

Are you financially independent? Yes No

Are you a client of Vocational Rehabilitation Services? Yes No

Do you receive supplemental security income (SSI)? Yes No

Do you receive social security disability income (SSDI)? Yes No

Have you ever lost your SSI or SSDI benefits? Yes No

Employment

Do you currently have a job? Yes No

If yes, how many hours do you usually work per week during school?

What is your job title?

What are your job duties?

Is your job considered full-time or part-time? Full-time Part-time

Is your salary below, at or above the minimum wage of $5.15/hr?

Below At Above

What are your job benefits? Please mark all that apply.

None	Promotion	Sick leave
Vacation	Life insurance	Dental insurance
Health insurance	Profit sharing	Free meals
Child care	Job training	Other:

Family Background

How much education did your parents complete? Please mark those that apply.

Father	Level of education	Mother
	Less than high school
	HS diploma/GED
	Some college
	College graduate
	Post graduate degree

With whom do you live now? Please mark all that apply.

Mother	Father	Step mother	Step father
Alone	Spouse	Friend/ roommate	Significant other
Children	Other family	Foster parents	Other

Do you live in a house, apartment or do you have some other living arrangement? Please circle.

House Apartment Dormitory Boarding or rooming house

Other

Social Activity Information

Do you have a current driver's license? Yes No

How do you mostly travel around the community? Please circle one.

Own car Parent's car Bike Bus Friends drive Wheelchair

Walk Other

Think of your three best friends in high school and answer the following questions with them in mind. Write in 0, 1, 2, or 3.

How many are currently in high school? of three are in high school

How many dropped out of high school? of three dropped out

How many are/were in a GED program? of three in a GED program

How many graduated from high school or completed their GED? of three graduated

How many attended college? of three attended college

How many attended a vocational or technical school? of three attended Vo-tech

Besides classes, colleges have a number of other activities. In what activities do you or did you regularly participate? Please mark all that apply.

None	Student government	Drama
Varsity sports	Intramural sports	Music
Dean's list	Yearbook/newspaper	Vocational clubs
Academic clubs	Others

Do you belong to any clubs or organizations that are separate from school? Yes No

If yes, in which one are you the most active?

Think back over the past two weeks. What are some activities you did with your friends?

During the past two weeks, how many times did you attend or participate in each of the following? Please approximate and write a number in each space provided (0, 1, 2, 3...)

Attend the movies	Attend a sporting event
Visit a museum	Visit a public library
Attend live theatre	Attend concerts
Attend religious activities	Eat at a restaurant/carry out
Extended travel out of town, Distance ___________________ miles		Other public function (specify)

Disability Please mark the verified disability/disabilities that apply to you.

Visual impairment or blindness	Mental retardation
Deafness/hard of hearing	Emotional/behavioral disorders
Orthopedic/mobility disabilities	Head injuries
Speech/language disorders	Chronic illnesses
Learning disabilities	Other (specify)

Have you had a required course(s) waived because of your disability?

Yes No

If yes, which course(s)?

Have you had a course(s) substituted because of your disability? Yes No

If yes, which course(s)?

Have you had a class assignment(s) waived because of your disability? Yes No

If yes, which assignment(s)?

Have you had a substitute class assignment(s) because of your disability? Yes No

If yes, which assignment(s)?