Fillable ADA Verification Form (Nashua Community College)

Fill Online, Printable, Fillable, Blank ADA Verification Form (Nashua Community College) Form

Use Fill to complete blank online NASHUA COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ADA Verification Form (Nashua Community College)

On average this form takes 15 minutes to complete

The ADA Verification Form (Nashua Community College) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Nashua Community College

BROWSE NASHUA COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1 of 2 | NCC ADA
NCC Student Name: ____________________________________________________ Date of Birth: ______________________
Professional’s Name: _____________________________________________________________
I am a: ____ Medical Dr. ____ Psychiatric Dr. ____ Licensed Counselor Other: _______________________
Practice Name: ____________________________________________________________________________________________________
Address_____________________________________________________________________________________________________________
Phone ______________________________________ Fax ______________________________________
The above person is applying for disability services at NCC. To assist our office in making the most
appropriate determination for accommodations, the following information is requested.
Please complete the entire form. If you have questions, call (603) 578-8996.
1. Statement of Condition/Disability: _____________________________________________________________________________
____________________________________________________________________________________________________________________________________
2. Summary of assessment procedures/evaluations used to make the diagnosis: _____________________________
_________________________________________________________________________________________________________________________
3. The listed Condition/Disability is: ______ Permanent/Chronic: ______ Temporary:
Severity is: ______ Mild ______ Moderate ______ Severe
4. List all current medications/possible side-effects that could potentially impact academic performance:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
5. In your professional opinion, is this a condition that substantially limits one or more major life
activities as defined by ADA standards (42 U.S. Code § 12102 - Definition of disability)? Major life
activities are functions such as caring for oneself, performing manual tasks, walking, seeing, hearing,
speaking, breathing, learning and working.
IN ORDER for a student to qualify for classroom accommodations in college, the professional must be able to say YES
to the above statement. CHECK ONE: ______ YES ______ NO
ADA Verification Form
THIS FORM MUST BE COMPLETED & SIGNED BY A LICENSED PROFESSIONAL
2 of 2 | NCC ADA 05-21-2020
NCC Student Name: _______________________________________
6. Functional Limitations within an academic setting (due to disability):
______ limited ambulation ______ visual acuity ______ hearing impairment [degree:________________________]
______ easily distracted ______ severe test anxiety ______ difficulty maintaining stamina/energy
7. SUBSTANTIAL DIFFICULTY WITH:
______processing auditory information ______concentrating ______memorizing information
______ use of hands ______expressing self in writing ______ processing visual information
______ reading/decoding ______handling time pressures/multiple tasks ______ responding to change
______responding to negative feedback ______ responding to authority figures other: ______________________________
8. Services and accommodations that you would recommend for this student that are SPECIFICALLY
related to symptoms and diagnosis (please include rationale if needed):
______ extended time on tests ______ copies of notes ______ audio books
______ extra time for clarification ______digitally record lectures ______ use of calculator
______sign language interpreter ______scribe or reader for tests ______preferential seating
______ physical breaks from class ______ meet with Coordinator weekly/bi/monthly
______ reduced distraction testing environment other: ______________________________
9. List other accommodations that you might recommend and rationale: ________________________________________
___________________________________________________________________________________________________________________________________
Professional’s Signature Required:
Name:__________________________________________________________________________________
Signature:______________________________________________________________________________ Date:______________________________
Title/Credentials and License Number: _________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Note: Disability documents are kept separate from academics records are retained in the Disability Services
Office.
Return this form to: NASHUA COMMUNITY COLLEGE
Attn: Disability Services Office
Mail: 505 Amherst St.
Nashua, NH 03063
Email: jquinn@ccsnh.edu
Fax: (603) 883-1636
Phone: (603) 578-8996
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ADA Verification Form (Nashua Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 September 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document