Disability Verification Form Disability Services (DS) at Columbus State Community College provides academic accommodations and services for students with diagnosed disabilities. Thank you for supporting our student by completing this form. The documentation you provide on this form regarding the disability diagnosis must establish that the student has a disability covered under Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act (ADA) of 1990. The ADA defines a disability as: a physical or mental impairment that substantially limits one of more major life activities. This form has been developed to assist the student in working with his/her treating or diagnosing healthcare professional (psychiatrist, psychologist, counselor, therapist, social worker, medical doctor, optometrist, speech-language pathologist, etc.) in obtaining specific information needed to evaluate eligibility for academic accommodations. The healthcare professional(s) conducting the assessment and/or making the diagnosis must be qualified to do so. These persons are generally trained, certified, or licensed to diagnose medical or mental health conditions. All parts of the form must be completed as thoroughly as possible. Inadequate information, incomplete answers, and/or illegible handwriting will delay the eligibility review process by necessitating follow-up contact for clarification. It is recommended that this form be completed by typing the information into the editable PDF document available on our website: www.cscc.edu/disability The healthcare provider should attach any reports which provide additional related information (e.g. psychoeducational assessments, neuropsychological test results, Individualized Education Programs [IEPs], etc.). If a comprehensive diagnostic record is available that provides the requested information, copies of that report can be submitted for documentation in lieu of this form. In addition to the requested information, please attach any other information you think would be relevant to the student s academic accommodation. The information you provide will be kept in the student s file at Disability Services, where it will be held securely and in accordance with FERPA regulations. This form may be released to the student at his/her request. If you have questions regarding this form, please call the DS office at 614-287-2570.
STUDENT INFORMATION (Please Print Legibly or Type) Name (Last, First, Middle): Date of Birth: Cougar ID Number: Status (check one): Are you currently enrolled at CSCC? Yes No Local phone: ( )- - Cell phone: ( )- - Address (street, city, state and zip code) CSCC E-Mail address: @student.cscc.edu 1. Primary diagnosis (including date of diagnosis): 2. Additional diagnoses, if any (including date of diagnosis): 3. Is the student/patient currently under your care? Yes No 4. What is the severity of the disorder? Mild Moderate Severe 5. Please describe the student s symptoms relating to this diagnosis, and how these symptoms will impact the student:
6. Please state the medication the student is currently prescribed, including side effects, if any: 7. Please describe any ancillary treatments (or therapies) the student is receiving: 8. If this is a temporary disability, what is the expected duration of the condition? 9. Describe any situations or environmental conditions that might lead to an exacerbation of the condition. 10. Do you feel this student is a danger to him/herself or others?
11. Major Life Activities Assessment: Please check which of the following major life activities listed below are affected because of the impairment. Indicate severity of limitations. Life Activity Negligible Moderate Substantial Not Sure Concentrating Thinking Learning Reading Writing Math calculation Memory Stress Management Managing internal distractions Managing external distractions Regular Class Attendance Keeping appointments Time Management Organization Social Interactions Self Care Sleeping Sitting Walking Seeing Hearing Lifting Performing manual tasks Breathing
12. In addition to the major life activities listed above, please describe any activities that may be impacted by the disability or symptoms that may need to be addressed in the college environment. 13. Please state specific recommendations regarding academic accommodations (e.g. extra time for exams, etc.) for this student. 14. Please add any additional comments that you feel appropriate:
HEALTHCARE PROVIDER INFORMATION (Please sign & date below and fill in all other fields completely using PRINT or TYPE) Provider Signature: Date: Provider Name (Print): Title: License or Certification #: Address: Phone Number: ( )- - FAX Number: ( )- - Important: Please return completed and signed form to the Disability Services office. The form may be hand delivered by the student, mailed, faxed, or emailed to: Disability Services Columbus State Community College 550 East Spring Street Eibling Hall 101 Columbus, Ohio 43216 Phone: (614) 287-2570 Fax: (614) 287-6054 Email: DsDocumentation@cscc.edu After documentation is reviewed, DS will send an email notification to the student s CSCC email account acknowledging receipt of documentation and informing student of his/her eligibility status.