Disability Verification Form

STUDENT INFORMATION

Full Name:
Last / First / M.I.
Address:
Street Address
City / State / ZIP Code
Phone:
Email:
Date of Birth:

Status (check one): current student transfer student prospective student

DIAGNOSTIC INFORMATION

  1. Primary Diagnosis (and date diagnosed): ______
  2. Additional Diagnoses (and dates diagnosed): ______

______

______

______

  1. Please state the medication or treatment the student is currently prescribed:

______

______

  1. Major Life Activities Assessment: Please check which of the following major life activities listed below are affected because of the impairment. Indicate severity of limitations.

Life Activity / Negligible / Moderate / Substantial / Don’t Know
Concentrating /  /  /  / 
Memory /  /  /  / 
Eating /  /  /  / 
Social Interactions /  /  /  / 
Self-Care /  /  /  / 
Regular Class Attendance /  /  /  / 
Speaking /  /  /  / 
Reading /  /  /  / 
Keeping appointments /  /  /  / 
Managing stress /  /  /  / 
Managing distractions /  /  /  / 
Sleeping /  /  /  / 
Organization /  /  /  / 
  1. In addition to the major life activities affected that are indicated above, please describe any activities that may be impacted by the disability or symptoms that may need to be addressed in the college environment:

______

6. Please state specific recommendations regarding academic accommodations: ______

7. Please add any additional comments that you deem helpful or appropriate:

______

Provider Signature / Date

______

Provider Certification NumberPhone Number

______

Provider Address

Please return completed form to:

Ohio State ATI

Student Success Services

Disability Services

1328 Dover Rd.

Wooster, OH 44691

Fax: 330-287-1205

Email: