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        Major Life Activities Form    

Student Name;______________________________ Social Security Number:____________________
                                   

Major Life Activity School Related Description of Impairment (1) Source of Information(2) Mild       Severe
Caring for oneself     1 2 3 4 5
Performing Manual Tasks     1 2 3 4 5
Walking     1 2 3 4 5
Seeing     1 2 3 4 5
Hearing     1 2 3 4 5
Speaking     1 2 3 4 5
Breathing     1 2 3 4 5
Learning     1 2 3 4 5
Working     1 2 3 4 5
Other (4)     1 2 3 4 5

1.  Description of educational related behaviors associated with specific major life activities affected by mental of physical condition
2.  Listing of persons and/or evaluation techniques used for identifying behaviors associated with impairment
3.  Based on consideration of the nature, severity, and duration of the impairment
4.  Other major life activities might include bending, stooping, reaching