Verification of Disability Form

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.
  • MM slash DD slash YYYY
  • Certifying Professional:

  • MM slash DD slash YYYY
  • 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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Impact of Condition on Educational Access

  • Max. file size: 6 MB.
  • Max. file size: 6 MB.
  • Max. file size: 6 MB.
  • Max. file size: 6 MB.