THE UNIVERSITYOF NORTH CAROLINAAT WILMINGTON
DISABILITY VERIFICATION FOR ATTENTION DEFICIT / HYPERACTIVITY DISORDER
To ensure the provision of reasonable and appropriate accommodations, a student requesting services must provide current documentation of the disability. This documentation should provide information regarding the onset, longevity, and severity of symptoms, as well as the specifics describing how it has interferes with educational achievement. Therefore, individualized assessments of current cognitive processing and educational achievement are necessary. The following questionnaire should facilitate this information gathering. Appropriate services will be determined from the specific information provided.
04/10
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RELEASE OF INFORMATION
I, (STUDENT) ______, hereby authorize the release of the following information to Disability Resource Center, UNCW, 601 South College Rd., WilmingtonNC28403-5942, for the purpose of determining eligibility for academic accommodation. Phone: 910-962-7555. FAX: 910-962-7556.
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DateSignature of studentUNCW student ID #
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Diagnostic code (ICD or DSM III-R, IV) ______
Level of Severity ______
Date of Diagnosis ______
Date of last visit ______
A. Symptom checklist: Inattention and/or Hyperactivity-Impulsivity persistent and to a degree that is maladaptive and inconsistent with developmental level.
Inattention
___a) often fails to give close attention to details or makes careless mistakes in school work, work, or other
activities.
___b) often has difficulty sustaining attention in tasks or play activities
___c) often does not seem to listen when spoken to directly
___d) often does not follow through on instructions and fails to finish school work, chores, or duties in the
workplace (not due to oppositional behavior or failure to understand instructions)
___e) often has difficulty organizing tasks and activities
___f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
___g) often loses things necessary for tasks or activities
___h) is often easily distracted by extraneous stimuli
___i) is often forgetful in daily activities
2
Hyperactivity-Impulsivity
___a) often fidgets with hands or feet or squirms in seat
___b) often leaves seat in classroom or in other situations in which remaining seated is expected
___c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or
adults, may be limited to subjective feelings of restlessness)
___d) often has difficulty playing or engaging in leisure activities quietly
___e) is often “on the go” or often acts as if “driven by a motor”
___f) often talks excessively
___g) often blurts out answers before questions have been completed
___h) often has difficulty awaiting turn
___i) often interrupts or intrudes on others
B. History: Some hyperactive-impulsive or inattentive symptoms causing impairment were present before age 7years, as based on: ______Family report
______School records
C. Some impairment from the symptoms is present in two or more settings.
D. There is clear evidence of clinically significant impairment in social, academic, or occupation setting.
Evidence of a significant impairment to learningMUSTaccompany this documentation. Attach report including: tests administered, test results, specific recommendations for accommodations, and
justification for each accommodation recommended.
Academic ImpairmentAcademic Accommodation Recommended
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______
______
______
Failure to provide recommendation for accommodation and justification for these recommendations
will result in an inability to accommodate this student.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder.
Medication prescribed______Response to Rx ______
Therapy prescribed ______
Evaluating professional is to be a licensed or otherwise qualified professional who has undergone appropriate and comprehensive training in the diagnosis of AD/HD and has no personal relationship with the individual being evaluated.Provider’s name______Title ______
Address ______Phone(s)______
______
Signature ______Date ______
DISABILITY RESOURCE CENTER
DIVISION OF STUDENT AFFAIRS
601 SOUTH COLLEGE ROAD, WILMINGTON, NORTH CAROLINA28403-5942
PHONE 910-962-7555 FAX 910-962-7556 TTY 800-735-2962