Brigham Young University Independent Study

Brigham Young University Independent Study Students with Special Learning Needs DOCUMENTATION OF DISABILITY

NOTE: Please complete this form and attach any additional relevant written reports and test scores. Thank you.

Name: ______Course Access Code: ______Birth Date: ______Address: ______City/State/ZIP: ______Phone: ______

Diagnosis: ______Symptoms: ______Tests/Procedures Used to Diagnose Condition (list briefly): ______Interpretation of Results (lay terms, please): ______Severity: ______Expected Duration of Disability: ______Brief History/Prognosis for Treatment: ______Medications and Side Effects Patient Experiences: ______Functional Limitations: How and to what extent does the disability limit the patient’s ability to perform learning tasks or functions required in a classroom environment? ______Accommodative Recommendations: ______Diagnosed By: ______Report Date: ______Address: ______City/State/ZIP: ______Phone: ______Fax: ______

Physician’s Signature: ______Date: ______

Fax to BYU Independent Study, Attn: Testing Supervisor, 801- 812-8847 Mail to BYU Independent Study, Attn: Testing Supervisor, 120 MORC, Provo, UT 84602-0300