St. Olaf College
Student Accessibility Services

Verification of Disability Form


The student named below is requesting accommodations due to the impact of a disability. To evaluate that request, our office is requesting that the following 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.


The provision of reasonable accommodations is based on assessment reports and the current impact of the disability on academic performance.


It should be noted that academic accommodations are intended to ensure access to educational opportunities for students with disabilities, not to make adjustments that would fundamentally alter the nature of the course, course components, or course requirements.


Student:

Last Name First Name MI

Date of Birth / / Phone


Certifying Professional:

Name
Professional Title
License/Certification Number and Issuing State
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. Date: 05/25/2013


Diagnosis

Please attach any assessment reports and/or scores from any diagnostic tests that were used to support this diagnosis.

Diagnosis

Date of Diagnosis: / / Review Date of Diagnosis: / /

Initial contact with student: / / Last contact with student: / /

Level of severity of the disorder:
Mild  
Moderate  
Severe  


Expected duration:
Permanent  
Chronic/recurring  
Temporary  
Not Applicable  


Description of symptoms:



Please describe the setting in which these symptoms have been most evident:



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


How does this condition currently limit this student's ability to learn or meet the expectations of a college environment?



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.



Please list any recommended academic accommodations here.



Please attach any files here: