Disability Verification Form

Hood College

Disability Services

401 Rosemont Avenue

Frederick, MD 21701

DISABILITY VERIFICATION FOR MEDICAL CONDITIONS

This form must be completed in order for students to receive services through the Disability Services Coordinator (DSC) at Hood College.

Attending physician please complete the following:

Patient name: ______

Patient’s date of birth: _____ / _____ / ______

Patient’s social security number: ______- ______- ______

Medical Information:

Specific Diagnosis:______

Initial Date of Treatment: ______/ ______/ ______

Date of Last Visit: ______/ ______/ ______

Date of Next Visit: _____ / _____ / ______

The Expected Duration of the Condition/Disability:

Permanent

  Temporary: Expected date of recovery ______/ ______/ ______

Note: Should the student’s condition change (for better or worse), the student must provide updated documentation so his/her accommodations could be adjusted accordingly.

Top of Form
Please check which of the major life activities listed below are affected because of the medical diagnosis. Please indicate the level of limitation.
Life Activity / mm / No Impact / ModerateImpact | / Substantial Impact / Don't Know
Concentrating / .
Memory
Sleeping / .
Eating
Social Interactions / .
Self-care
Managing internal distractions / .
Managing external distractions
Timely submission of assignments / .
Attending class regularly and on time
Making and keeping appointments / .
Stress management
Organization / .
Bottom of Form

Treatment Plan:______

______

______

(If the plan includes study skills workshops, career or personal counseling, the patient is expected to arrange for this and follow through on his/her own)

As a result of the aforementioned medical condition, the impact on the patient in terms of doing college level work is such that he/she will be:

  Totally Incapacitated and should:

____ Withdraw from college at this time.

____ Not register for college this semester and take a leave of absence.

____ Other______

  Partially Incapacitated and has been advised to:

____ Reduce his/her academic course load

____ Other (please specify) ______

______

______

  Minimally Impacted.

-Please indicate what academic accommodations need to be made based on medical necessity (e.g. note takers, extended time for tests, large print etc..) ______

______

______

______

Does the patient take any medications? If so, please list quantity and frequency?

1. ______2. ______

3. ______4. ______

What potential side effects are associated with the medication(s) listed above?

______

______

Given the current medical condition of the patient, are there any non-academic accommodations he/she will need? Please list. (E.g. Accessible parking).

______

______

______

Please return this form within two weeks of receiving it to:

Disability Services Coordinator

Hood College

401 Rosemont Avenue

Frederick, Maryland 21701

Fax: 301-696-3952

4