Disability Verification Form
Student Information
Student name
First Name
Last Name
Date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of last clinical check
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List the student’s disability/medical condition and current symptoms
The conditions substantially limits the following major life activities
Class attendance
Caring for self
Communicating
Social interactions
Perform manual tasks
Organization
Concentration
Interpersonal skills
Memorizing
Reading
Writing
Sitting
Other
Provide a detailed explanation of how the disability impacts the student's ability to function within an academic environment
Describe medical treatments, therapies, devices, or regimens prescribed including compliance, and response to intervention about how symptoms/disabilities are currently being treated or controlled
Expected duration of disability
Permanent
Temporary
Remitting/relapsing
Explain the expected duration of impact on the student
Medical Professional Information
Certified/licensed professional name
First Name
Last Name
Specialty
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of certified/licensed professional
Submit
Should be Empty: