Download disability verification for medical conditions

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.
Disability Verification 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 Moderate Impact Substantial Don't
Impact
|
Impact 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 .
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)
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Disability Verification Form
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?
________________________________________________________________________
________________________________________________________________________
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Disability Verification Form
Given the current medical condition of the patient, are there any non-academic
accommodations he/she will need? Please list. (E.g. Accessible parking).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Name and contact information for Attending Physician (Please use office stamp)
Physician Signature: ____________________________ Date: __________________
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
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