DearMedicalService Provider:
Inorderforstudentstoreceive disability-relatedaccommodationsatHaywoodCommunityCollege, it isnecessarytohave documentationregardingthe student’sdisability/medicalcondition. HaywoodCommunity College wouldappreciate youproviding us with(1) a diagnosis,(2)howthisconditionmightaffect his/her academicprogress,and(3) recommendationsforappropriate classroomaccommodations. Thank youforyourassistance.
DiagnosisTemporaryDisabilityPermanentDisabilityDisabilitythatisepisodicorinremission
ADHD
ChronicMedicalCondition
HearingImpairment
LearningDisability
Physical/MobilityImpairment
Psychological/PsychiatricDisability
VisualImpairment
Other
Howmightthisconditionaffectacademicprogress?Check allthatappliestothisstudent.Pleasefeelfreetoaddanyotherlimitationsthatarerelatedtothediagnosisand/ormedicationsusedtotreatthatcondition.Pleaseexplainasneeded.
caringforoneself
performingmanualtasks
seeing
hearing
eating
sleeping
walking
standing
lifting
bending
speaking
breathing
learning
reading
concentrating
thinking
communicating
working
functionsoftheimmunesystem
normalcellgrowth
digestivefunctions
bowelfunctions
bladderfunctions
neurologicalfunctions
brainfunctions
respiratoryfunctions
circulatoryfunctions
endocrinefunctions
reproductivefunctions
Describethecurrentimpactofthedisability/medicalconditiononthestudent:
Whichofthefollowingclassroomaccommodationswouldbeappropriatetoaddressconcernsrelatedtothediagnosisabove?
Extended(1½)timeforquizzes,tests,andexams
Testinginadistractionfreeenvironment/separateroom
Softwarethatconvertswrittentexttovoice(notpermissiblefortestsofreadingability)
Tutoring/Drop-InLab
Volunteernotetakingservices,ifclassnotes/lecturearenotavailableelectronically
Useofdigitalrecorder(lecture)
Adaptiveequipment–useof:
Priorityseating(infrontofclass/nearinstructor)
Sameseatforallclassmeetings
Seatingforwheelchair
Handicappedparking
SafetyPlan–seeattachedplan
Other
Thisstudenttakesmedicationthatmay
PhysicianSignatureDate
DearStudent,
In orderfor Haywood CommunityCollege to provide reasonableandappropriateaccommodations, it isnecessaryto havedocumentation regardingyourdisability/medical condition. Please takethis formtoyourmedicalprovider. This form will assistyourmedical providerin describing yourdisability/medical conditionandneed for accommodations.
Ifyourmedical provideroryou have questions,Imaybe contactedat:
Susannah High
Counselor
Haywood CommunityCollege 185 Freedlander Drive
Clyde, NC 28721828.627.4504(phone)828.627.4513 (fax)
Office#1532
Ilook forward to workingwithyou.Please do nothesitate to contactme.Sincerely,
Susannah High
Name ofMedicalOffice
Name ofMedical Service Provider
Address
Phone
Fax