Disability Verification Form

CENTER FOR ACADEMIC ACHIEVEMENT & RETENTION (CAAR)

DISABILITY SERVICES COORDINATOR

Rosenstock Hall, Suite 330 Contact: 301-696-3569

TO BE COMPLETED BY THE STUDENT’S HEALTH CARE PROFESSIONAL

A disability is defined under the Americans with Disabilities Act as “a physical or mental impairment that substantially limits one or more major life activities.” Examples of major life activities are: seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, thinking, concentrating, learning, reading, communicating, working, performing manual tasks, caring for oneself, and the operation of major bodily functions. A temporary impairment may include an injury, severe illness, recovery from surgery, or a condition caused by a traumatic event.

STUDENT NAME: ______DATE OF BIRTH: ____/____/____

CARE PROVIDER INFORMATION:

PROVIDER NAME: / CREDENTIALS / LICENSING
PROVIDER PRACTICE NAME & ADDRESS (OFFICE STAMP ACCEPTABLE)
OFFICE PHONE NUMBER: / OFFICE EMAIL:

Under ADA, this individual’s disability is considered:

_____ Permanent ______Temporary

If temporary, the anticipated duration of the condition is ______.

Note: Should the student’s condition change (for better or worse), the student must provide updated documentation so his/her accommodations could be adjusted accordingly.

  1. Please cite the student’s diagnosis:

Dx #1: ______Diagnostic code: ______

Dx #2: ______Diagnostic code: ______

Dx #3: ______Diagnostic code: ______

Criteria from: _____DSM-IV-TR _____DSM-V ______ICD-9 _____ICD-10

  1. Date of initial diagnosis: ______Made by you? ______

No, Dx made by: ______

  1. Does the individual see you on a scheduled basis?

____Yes ____No _____ When necessary

  1. Date of most recent evaluation: ____/____/____
  1. Currently under your care: _____ Yes ______No, ended on: ___/____/____
  1. Does the patient take any medications? If so, please list quantity and frequency?

1. ______2. ______

3. ______4. ______

What potential side effects are associated with the medication(s) listed above?

______

______

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Please check which of the major life activities listed below are affected because of the medical diagnosis. Please indicate the level of limitation.
Life Activity / mm / No Impact / ModerateImpact | / Substantial Impact / Don't Know
Concentrating / . / / / /
Memory / / / /
Sleeping / . / / / /
Eating / / / /
Social Interactions / . / / / /
Self-care / / / /
Managing internal distractions / . / / / /
Managing external distractions / / / /
Timely submission of assignments / . / / / /
Attending class regularly and on time / / / /
Making and keeping appointments / . / / / /
Stress management / / / /
Organization / . / / / /
Bottom of Form

OTHER:

______

______

______

Academic Accommodation Recommendations:(check all that apply and feel free to add notes)

Preferential seating
Testing in Hood College testing center (CAAR)
Extended Time ( x1.5)
Extended Time (Double time)
Private room in testing center
Peer Note-Taker
Use of computer when testing
Scribe (or audio recording) when testing
Lecture / faculty notes (consent from faculty needed)
Recorded lectures (consent needed)
May use basic calculator
Transcriptions for audio formatted material (i.e. podcasts)
Furniture:
_____ standing desk / lecturn
_____ wide desktop
_____ special chair / Enlarged Font: _____ font size
Accessible Texts:
_____audio _____PDF
_____ e-texts _____ Braille
______Other: ______
Use of Kurzweil
Use of LiveScribe
Use of Dragon Speak
Enlarged iPad
Other: ______
______
We provide free academic tutoring, do you recommend:
Writing Center support
Math Skills support
Subject area tutors
Negotiated due dates when multiple assignments are due (The student will be advised this must be done early and not the week / day of assignment due. This also does not excuse a student from missing work due to absence.) / Absence due to medical flares or occurrences out of student control. This does not excuse student from work.
(The student will be advised to review an Attendance Modification with faculty to discuss a reasonable number of absences and how work will be made up.)

OTHER Recommended Academic Accommodations:

______

______

______

As a result of the aforementioned medical condition, the impact on the patient in terms of doing college level work is such that he/she will be:

Totally Incapacitated and should:

____ Withdraw from college at this time.

____ Take a medical leave of absence.

____ Other (please specify) ______

______

______

Partially Incapacitated and has been advised to:

____ Reduce his/her academic course load (please be specific)

____ Other (please specify) ______

______

______

Minimally Impacted (recommend.

____ Other (please specify) ______

______

______

Given the current medical condition of the patient, are there any non-academic accommodations he/she will need? Please list. (E.g. Accessible parking).

______

______

Please provide any necessary reports (i.e. Neuro-psychoeducational reports, medical documentation).

Please return this form within two weeks of receiving it to:

Disability Services Coordinator

Hood College

401 Rosemont Avenue

Frederick, Maryland 21701

Fax: 301-696-3952

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