Fillable Add Adhd Documentation Form (Jacksonville University)

Fill Online, Printable, Fillable, Blank Add Adhd Documentation Form (Jacksonville University) Form

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

Add Adhd Documentation Form (Jacksonville University)

On average this form takes 6 minutes to complete

The Add Adhd Documentation Form (Jacksonville University) form is 6 pages long and contains:

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

Country of origin: US
File type: PDF

U.S.A. forms for Jacksonville University

BROWSE JACKSONVILLE UNIVERSITY 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 | Page
JACKSONVILLE UNIVERSITY
Disability Support Services
2800 University Blvd. N.
Jacksonville, FL 32211
Phone: (904) 256-7067 -- Fax: (904) 256-7066
Documentation Guidelines
Welcome to the office of Disability Support Services (DSS) at Jacksonville University (JU). To be
eligible for services at the DSS, a student must satisfy the definition of a disability as established
by the Americans with Disabilities Act of 1973. Section 504 defines a disability as a
condition which substantially limits one or more major life activities such as
learning, walking, seeing, hearing, breathing, caring for oneself, and working. To
be eligible for accommodations, a student must provide appropriate documentation of each
disability that demonstrates an accompanying substantial limitation to one or more major life
activities.
The following guidelines are provided in the interest of assuring that professionals’ statement is
appropriate to document eligibility for support services. The student with a disability must
provide the office of DSS appropriate written documentation from a licensed professional in the
field concerning the specific diagnosis and expected academic limitations.
The documentation must be within the last 3 years. However, the DSS reserves the
right to make modifications to this time frame.
I, __________________, hereby authorize the following information as well as any
other pertinent documentation to be forwarded to the office of Disability Support Services at
Jacksonville University for the purpose of determining my eligibility for academic
accommodations.
Student’s Signature:
Date:
2 | Page
Documentation Guidelines for Attention Deficit/Hyperactivity Disorder
After completing this form, please fax, mail or email it to the office of Disability Support
Services at the end of this document. UThe information you provide will not become a
part of the student’s educational records but will be kept in the student’s file at Disability
Support Services where it will be kept confidential.U Please contact staff at the office of
Disability Support Services if you have questions or concerns. Thank you for your
assistance.
The diagnostician UmustU address all the following six criteria in diagnosing AD/HD:
1. Evidence that anxiety disorders, disorders of depression, mood disorder,
schizophrenia, border-line personality disorder, dissociative disorder or
substance-related disorders are not the primary disability and are not the
primary cause of AD/HD.
2. Standardized assessment measures of attention are utilized in the diagnosis of
AD/HD; (i.e., T.O.V.A., Continuous Performance Test, neuropsychological
evaluation).
3. Reported history of AD/HD symptoms by the age of seven, corroborated by
another independent source.
4. Corroboration of current AD/HD symptoms across multiple settings by one or
more adults with knowledge of the client’s functioning.
5. Documentation on two rating scales of AD/HD behaviors/symptoms that have
appropriate age norms (i.e., rating scales for childhood and adult behavior).
6. Evidence of interference of AD/HD with appropriate academic or social
functioning.
3 | Page
Documentation Guidelines for Attention Deficit/Hyperactivity Disorder
Student's Name: _____________________________________
Date: U _________________________
1. Statement of DSM V diagnosis (DSM V classification and subtype).
2. Date of diagnosis and date student last seen for treatment or evaluation.
3. Procedures and instruments used to make the diagnosis (e.g., clinical interview,
behavior rating scales, neuropsychological or psychoeducational testing, names
of tests).
Date of Diagnosis:
Date Last Seen:
4 | Page
4. Past symptom(s):
5. Interpretive summary of evaluation results, including all standardized scores that
are available. The information derived from the instruments or procedures used
to reach the conclusion that the student meets criteria for ADHD is required.
Attach additional information as necessary.
6. Current symptoms that meet the criteria for diagnosis (Note that diagnosis based
on DSM IV criteria include six or more symptoms of inattention and/or six or
more symptoms of hyperactivity and impulsivity.
5 | Page
7. Information related to co-occurring symptoms or how other diagnoses were ruled
out.
8. Currently prescribed medications, and the impact of the medications on the
student’s ability to meet the demands of the academic program.
9. Ways in which current symptoms of ADHD interfere with Uacademic achievement.
10. Recommendations for academic accommodations to minimize the impact of the
disability on the student’s academic performance.
6 | Page
11. Ways in which current symptoms of ADHD interfere withU living on campus
and/or having a meal plan Uand whether the student be exempt from living on
campus and/or having a meal plan? Please answer and explain.
Student Name:
Professional Signature: Date:
Print Name, Title, Degree:
Professional License Number:
Contact Information:
Thank you for your prompt response to this request. Please return this information to:
Ol
ga L. Florez, M.Ed., M.P.A
Director, Disability Support Services
Davis Student Commons, 3
P
rd
P floor
Division of Student Affairs
2800 University Blvd. N.
Jacksonville, FL 32211
Email:
oflorez@ju.edu
30TU U30T
Phone: (904) 256-7067-- Fax: (904) 256-7066
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

Add Adhd Documentation Form (Jacksonville University)

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 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document