Reasonable Accommodations Verification Form

The student named below is requesting accommodations due to the impact of a disability. In order to make proper determinations, we request this form be completed by a qualified professional who has first-hand knowledge of the student's condition and is an impartial individual not related to the student. If you prefer to provide a letter instead, please ensure it includes the details requested in this form.

Last Name
First Name
Middle Initial
Date Of Birth
MM slash DD slash YYYY
Certifying Professional:
Name
Professional Title
License/Certification Number and Issuing
Agency
Address
City
State
Zip
Phone
Fax
Email
By checking this box, I verify that I am the certified professional stated above, and I verify that all information is correct according to the records on file.*
- I verify
By checking this box, I verify that I have received a signed release of information from the patient/student and his/her consent has been given to provide the information in this form.*
- I verify
Date of Initial contact with student
MM slash DD slash YYYY
Last visit contact with student
MM slash DD slash YYYY
Diagnosis
Please attach any assessment reports and/or scores from any diagnostic tests that were used to support this diagnosis.
Diagnosis
Date of Diagnosis:
MM slash DD slash YYYY
Review Date of Diagnosis
MM slash DD slash YYYY
Level of severity of the disorder:*
- Mild
- Moderate
- Severe
Expected duration:
- Permanent
- Chronic/recurring
- Temporary
- Not Applicable
Description of symptoms:*
Please describe the symptoms' frequency, intensity, and duration as well as the settings where they are most prevalent:*
Substantial Limitations: The ADA defines a disability as a condition that SUBSTANTIALLY LIMITS the individual. Does this diagnosis and resulting symptoms substantially limit the student and if so, how?*
If this student is taking medication for the disability, describe the medication(s), side effects, and potential impact on academic work:
Impact of Condition on Educational Access
List any parts of the college experience (classroom, housing, dining, facilities) that all other students have access to which may not be possible for your client solely as a result of their condition?*
We welcome suggestions of potential reasonable accommodations you would like us to consider as we evaluate the student's request.
Please provide any additional information you believe would be helpful so that we can provide effective service (e.g. threat to self or others, history of hospitalizations, any known effective academic interventions). Attach additional sheets as necessary and include results of related assessments.
Attach files
Max. file size: 6 MB.
Max. file size: 6 MB.
Max. file size: 6 MB.
Max. file size: 6 MB.
Send copy of completed form to the following email address.

Reasonable Accommodations Verification Form

Reasonable Accommodations Verification Form

Certifying Professional:

Diagnosis

Impact of Condition on Educational Access