Fillable Autism Spectrum Disorder And Aspergers Syndrome Documentation Form (Jacksonville University)

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Autism Spectrum Disorder And Aspergers Syndrome Documentation Form (Jacksonville University)

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The Autism Spectrum Disorder And Aspergers Syndrome Documentation Form (Jacksonville University) form is 7 pages long and contains:

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  • 14 check-boxes
  • 35 other fields

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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:
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AUTISM SPECTRUM DISORDER DOCUMENTATION FORM
Student’s Name: _________________
Date of Birth: _____________________
The student named above is applying for disability accommodations and/or services through the
Disability Support Services (DSS) at Jacksonville University. In order to determine eligibility, a
qualified professional must certify that the student has been diagnosed as having Autism
Spectrum Disorder/Asperger’s Syndrome and must provide evidence that it represents a
substantial impediment to a major life activity. It is important to understand that a diagnosis in
and of itself does not substantiate a disability. This documentation form was developed as an
alternative to a traditional diagnostic report.
The form be completed with as much detail as possible as a partially completed form or
limited responses will hinder the eligibility process.
The assessment information is current:
For students just graduating high school, an evaluation reflecting current levels of academic
skills should have been administered while in high school
For students who have been out of school for a number of years, documentation will be
considered on a case by case basis.
The form is completed by a professional who has comprehensive training and direct
experience in the differential diagnosis such as a psychologist, neurologist or psychiatrist.
The professional completing the form is not a family member of the student or someone who
has a personal or business relationship with the student.
1. What is the DSM-V diagnosis for this student?
2. Date of last contact with student:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V (GAF score):
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3. How long has the student had this diagnosis/condition?
4. What are the student’s primary current symptoms and concerns?
5. What is the severity of the symptoms?(please check one)
Mild
Moderate
Severe
Explain the severity indicated above:
6. Date(s) current assessment completed:
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7. State the frequency of appointments with student (e.g., once a week, twice a month):
8. Psychological History – Provide pertinent psychological history (include any
psychological reports or testing utilized, if applicable): (attach supporting documents if
needed)
9. Psychosocial History – Provide pertinent information obtained from the
student/parent(s)/guardian(s) regarding the student’s psychosocial history (e.g., history
of not sustaining relationships, history of employment difficulties, history of educational
difficulties, social inappropriateness, history of risk- taking or dangerous activities, etc.):
(attach supporting documents if needed)
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10. State the student’s functional limitations from the disorder specifically in the college
setting:
11. Other pertinent information:
Please complete the following table based on the impact that the student’s condition has on the
particular activity of behavior:
Activity/Behavior
No Impact
Substantial Impact
Don’t Know
Social interaction
Social awareness
Oral expression
Listening comprehension
Completing tasks
independently
Organization
Distractibility
Adherence to strict routines
Sensory sensitivity
Repetitive behaviors
Time management
Mathematics
Reading
Writing
Other (please specify)
12. List the student’s relevant current medication(s), including dosage, frequency, and
adverse side effects:
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13. Provide an explanation of the extent to which the medication currently mitigates the
symptoms of the condition:
14. State specific recommendations regarding academic adjustments, housing
accommodations, auxiliary aids, and/or services for this student and the reason these
academic adjustments, housing accommodations, auxiliary aids, and/or services are
warranted based upon the student’s functional limitations.
Continues on the next page,
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Certifying Professional:
Professional Signature:
Date:
Print Name, Title, Degree:
Professional License Number:
Company/Office/Institution Affiliation Name:
Contact Information
Address:
Phone #:
City, State, Zip :
Fax #:
Thank you for your prompt response to this request.
Please return any pertinent information to:
Olga L. Florez, M.Ed., M.P.A
Director, Disability Support Services
Davis Student Commons, 3
rd
floor
Division of Student Affairs
2800 University Blvd. N.
Jacksonville, FL 32211
Email: oflorez@ju.edu
Phone: (904) 256-7067 -- Fax: (904) 256-7066
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Autism Spectrum Disorder And Aspergers Syndrome Documentation Form (Jacksonville University)

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Completed 24 July 2020

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