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Disability Verification form

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Disability Support Services (DSS)

321 Golf Club Rd, SSC 248

Pleasant Hill, CA 94523

925-969-2182

Fax: 925.687.1829

Disability Verification Form

The student named below has requested specialized services at Diablo Valley College. In order to provide services we must have a verification of disability as defined on the reverse side of this sheet.

Name:______________________________________

Student ID#:________________

Date of Birth:________________

Description of Disability:

Acquired Brain Injury

_________________________________

Intellectual

_________________________________

Hearing (Attach a copy of current audiogram)

_________________________________

Mobility

_________________________________

Speech/Language

_________________________________

Visual

_________________________________

Other Health (list and describe specific diagnosis)

_________________________________

Learning Disability (Most current Cognitive & Achievement test results, including raw scores

________________________

Psychological (Indicate most current DSM and AXIS I and II Category and Code:)

________________________

Functional Limitations (check and/or fill in appropriate boxes):

ambulation

_________________________________

auditory processing

_________________________________

basic English/math skills

_________________________________

cognitive skills

_________________________________

degree of hearing loss

_________________________________

life planning

_________________________________

motor coordination

_________________________________

physical conditioning

_________________________________

poor concentration/memory

_________________________________

poor dexterity (hands/fingers)

_________________________________

visual acuity

_________________________________

visual processing

_________________________________

other

_________________________________

Side effects of prescribed medication:

_________________________________________________________

The above-mentioned disability is:

Permanent/Chronic

Temporary more than 45 days

Temporary 45 days or less

This disability is:

Observable

Not Observable

This verification is based on a review of records prepared by an identified licensed or certified professional who performed the diagnosis.

Certifying Professional Name: (Print )

_____________________________________________________

Certifying Professional Signature:

_____________________________________________________

Date:

_________________________________

Phone Number:

_________________________________

Address:

_________________________________

City:

_____________

State:

_____________

Zip:

_____________

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