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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) 2 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? ________________________________________________________________________ ________________________________________________________________________ 3 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 4