Verification of Disability for Determination of Accommodations

VINCENNES UNIVERSITY VERIFICATION OF DISABILITY FOR DETERMINATION OF ACCOMMODATIONS

PLEASE TAKE THIS COVER SHEET TO YOUR MEDICAL PROVIDER/PROFESSIONAL TO OBTAIN RELEVANT DOCUMENTATION. A good match between the credentials of the medical provider/professional making the diagnosis and the condition being reported is expected. For example: Learning Disabilities: Licensed Psychologist or Neuropsychologist Attention Deficit Disorders: Licensed Psychologist, Psychiatrist or Physician Psychiatric Impairments: Licensed Clinical Social Worker, Psychologist or Psychiatrist Medical/Health/Physical Disabilities: Physician/Medical Specialist within area of Disability

Student’s Full Name ______

Vincennes University Student ID Number (A#) ______

One of the following must be attached to this cover sheet to assist us in determining the most appropriate accommodations for this student’s disability. For Attention Deficit Disorders, Psychiatric Impairments, or Medical/Health/Physical Disabilities, you may use either of the (2) two documentation options listed below. For Learning Disabilities, please only use the “Diagnostic Test Report” option.

Diagnostic Narrative in letter format, typed on letterhead, with an original signature. We will not accept a Diagnostic Narrative for the verification of a specific learning disability. Please include in the narrative: -a specific diagnosis and the methods used to diagnose the disability -the CURRENT, specific symptoms manifested by this individual -a discussion of the ways this disability prevents full participation in classes

Diagnostic Test Report typed on letterhead, with an original signature. Please include in the report: -a list of all tests administered with all test scores and interpretations -the identification of global intelligence (IQ,) if identifying a learning disability -assessments of achievement and information processing, if identifying a learning disability -a diagnostic summary -the CURRENT, specific symptoms manifested by this individual -a discussion of the ways this disability prevents full participation in classes

Please also attach the student’s latest IEP or school plan to show a history of accommodation use

Specialist’s Printed Name ______

Specialist's Signature ______

Specialty Area ______

Contact Telephone Number ______Date ______Please forward all documentation to Leslie M. Smith, Director, Disability Services by one of the following: [email protected] ~OR~ 1002 N. First St, Vincennes, IN 47591 ~OR~ Confidential Fax: 812/888-2087 Effective 04-25-13