Download MUST BE COMPLETED BY A LICENSED PROFESSIONAL 

Services for Students with
Disabilities
1717 S. Chestnut Ave.
Fresno, CA 93702-4709
559-453-2247
wwwfresno.edu/disability-services
Verification of Disability
Student’s Name:
Date:
Address:
Student ID #:
MUST BE COMPLETED BY A LICENSED PROFESSIONAL1
1. Description of disability:
 Learning Disability
 Speech/language
Impairment
 Mobility Impairment
 Psychological Disability
2. Condition is:
3. Duration of disability:





ADD/ADHD
Autism
Hearing Impairment
Visual Impairment
Chronic Illness
 Dietary
 Traumatic Brain Injury
(including concussion)
 Other (please describe)
Stable
Prone to exacerbation
Permanent/chronic
Temporary (estimated duration of disability) __________________
4. Diagnosis/relevant medical history: _______________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Recommended services/accommodations:
Educational Activity
Writing in-class notes and assignments
Seeing or visually processing text
Hearing lectures and discussions
Taking tests
Using standard classroom curriculum
and format
Revised on 5/25/2017 3:56 PM
Recommended Accommodations2
 Note-taker
 Permission to record lectures
 Alternate format text
 Text-to speech software
 Preferential seating
 Oral description of the whiteboard
 Assistive listening device
 Sign language or oral interpreter
 Real time or closed/open captioning
 Preferential seating
 Extended time
o 1.5 X
o 2X
 Distraction-reduced setting
 Breaks
 Calculator
 Memory aids
 Assistive technology in classroom
 Permission to stand, move, leave briefly
 Lab assistant
 Personal attendant
 Leniency with attendance
 Extended due dates
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Campus Facility and Services
Facility
Housing
Emotional Support Animal (ESA)
Meal plan/dietary
Recommended Accommodations2
 Padded/ergonomic chair
 Separate table and chair
 On-campus transportation
 Other
 Single room
 Wheel-chair/handicap accessible room
 Ground-floor room
 Quiet room
 Personal attendant
 Other ________________________
 An ESA alleviates the following symptoms(s) or
effect(s):
o
o
o
o
 Full meal plan exemption*
 Reduction in meal plan*
o 140 block
o 70 block
*Indicate the specific reason for the meal plan
accommodation:
 Food allergies/sensitivities (e.g. peanuts, lactose
intolerant, gluten-free, etc.). Please list:
o
o
o
o
 Dietary requirements (e.g. high protein, high
fiber, etc.) Please list:
o
o
o
 Other ____________________________
Print name and title:______________________________________________________________
Signature:__________________________________________
Date:_____________________
1
A business card or script must be attached for this verification to be valid.
Additional documentation may be requested to support specific requested accommodation.
2
Return Address:
Melinda Gunning/ Services for Students with Disabilities
1717 S. Chestnut Ave. #13
Fresno, CA 93702
Revised on 5/25/2017 3:56 PM
769909903