Fillable Blindness And Visual Impairments Documentation Form (Jacksonville University)

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Blindness And Visual Impairments Documentation Form (Jacksonville University)

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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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Visual Impairments & Blindness Documentation Guidelines
1. Diagnosis: Please list all diagnoses and supporting numerical assessments of vision.
Visual Acuity with correction: _______________________________________
Visual Acuity without correction: _____________________________________
a. Approximate onset of diagnosis
□ Child – Approximate age: __________________________
□ Adolescent – Approximate age: ______________________
□ Adult – Approximate age: __________________________
□ Unknown
b. Duration of disability/impairment:
____ Permanent
____ Temporary: Expected date of recovery: _______ Month/Year: ____
c. Date of your last clinical contact with student: _______/_______/_______
2. Evaluation
a. How did you arrive at this diagnosis? Please check all relevant items below, adding
brief notes that might be helpful in determining eligibility for accommodations.
□ Medical Evaluation (x-ray, lab work, EKG, etc.).
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□ Standard eye exam.
□ Specialized eye exam: Specify __________________________________
□ Structured or unstructured interview with student.
□ Interviews with other persons (i.e. parent, teacher, therapist).
□ Behavioral observations.
□ other (please specify): ________________________________________
b. Evaluation Results:
c. Present symptoms that meet criteria for diagnosis being noted:
d. Current treatment being received by student:
□ Medication management
Current medications: __________________________________________
□ Other (please describe): ________________________________________
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e. Severity of symptoms:
□ Mild
□ Moderate
□ Severe
f. Prognosis of disorder:
□ Good (vision loss is stable)
□ Fair (vision loss is changing but individual retains functional level of sight)
□ Poor (vision is degenerative)
3. Functional Limitations
Please check below the major college life activities and academic functions listed below
that are affected by the disability/impairment in a college setting, indicating the level of
limitation.
Life Activity
Negligible
Moderate
Substantial
Walking
Breathing
Seeing
Hearing
Speaking
Sitting
Standing
Eating
Sleeping
Performing Manual Tasks
Learning
Thinking
Concentrating
Memory
Reading
Writing
Attending Class
Meeting Deadlines
Interacting with Others
Other:
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4. Are there any situations or environmental conditions that might lead to an
exacerbation of the condition?
5. Please indicate your recommendations regarding academic accommodations
and accompanying justifications for the student (e.g., note-takers, extended time
for tests, etc.).
Student Name:
Professional Signature:
Print Name, Title, Degree:
Professional License Number:
Contact Information:
Thank you for your prompt response to this request. Please return this 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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Blindness And Visual Impairments Documentation Form (Jacksonville University)

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Completed 24 July 2020

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