Copper Mountain College
ACCESS (DSPS)
PO Box 1398, Joshua Tree, CA 92252 (760) 366-3791 x5861
DISABILITY VERIFICATION
The student named below may be eligible for accommodations at Copper Mountain College as required by State and Federal law. In order to
provide services, we must have a verification of disability as defined on the reverse side of this sheet.
Last Name
First Name
MI
Date of Birth
ID#
Address
City
State
ZIP Code
Phone number
THE FOLLOWING SECTION MUST BE COMPLETED BY A LICENSED OR CERTIFIED PROFESSIONAL
Please include name and address of the professional and agency
Please provide the following information in full in order to assist us in determining reasonable educational accommodations:
Diagnosis of Disability(ies):
DSM IV Code and severity (if applicable):
Permanent/Chronic
Prone to exacerbation
Stable
Temporary estimated duration of disability
Area(s) impacted:
Reading
Math
Hearing
Test-taking
Mobility
Writing
Vision
Health/Physical
Note-taking
Check the descriptions that best describe the student’s educational limitations:
Limited visual acuity
Panics in unfamiliar surroundings and/or situations
Degree of hearing loss
Difficulty focusing for extended periods of time
Long term memory loss
Difficulty overcoming unexpected obstacles
Poor concentration
Difficulty formulating and executing plan of action
Short term memory loss
Limited ambulation
Easily distracted
Difficulty taking notes in classroom
Other:
If applicable, how do side effects of prescribed medications substantially limit major life activities in an educational setting?
A PHOTOCOPY OF THIS IS VALID AS THE ORIGINAL - Please fax completed form to (760) 366-5257 Attn: ACCESS
I understand the information provided with this form will become part of the student record subject to the Federal Family Education Rights
and Privacy Act of 1974 and may be released to the student upon their written request.
Certifying professional:
Print Name
Title
License No.
Phone
Signature
Date
If the above information is completed by someone other than the professional who made the diagnosis, please provide the name,
license no, address, and phone number of the person who made the diagnosis:
The Community College District uses the information requested on this form for the purpose of determining a student's eligibility to receive authorized special services provided by the Disabled Students Programs
and Services (DSP&S) Program. Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the
Chancellor's Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality,
including the Family Educational Rights and Privacy Act (20 U.S.C. 1232(g)). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. § 552a, note). The information on this form is being
collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000 et seq.
CONFIDENTIAL
COPPER MOUNTAIN COLLEGE
ACCESS
Disabled Student Programs and Services (DSPS)
Program Description
ACCESS (for students with disabilities) is a program that provides support services, specialized instruction, and
educational accommodations to students with disabilities so that they can participate as fully and benefit as equitably
from the college experience as their non-disabled peers. An Academic Accommodation Plan (AAP) is developed for
each student which links student’s goals, curriculum program, and academic adjustments, auxiliary aids, services
and/or instruction to his/her disability related educational limitation.
Eligibility Criteria
The specific disability must be verified, and there must be an educational limitation that precludes the
student from fully participating in general education without additional specialized services. This
documentation must be in the student’s file and must include the name and address of the professional
and/or agency verifying the disability.
Examples of Qualifying Disabilities
Note: This list does not contain all disabilities if unsure, please list the disability and the ACCESS Coordinator will make final
determination of eligibility for educational purposes.
Acquired Brain Injury
Other Health Conditions
ADD/ADHD
Cancer
Deaf and Hard of Hearing
Chemical Sensitivities
Blind and Low Vision
Chiari 1 Malformation
Learning Disability
Diabetes
Intellectual Disability
Fibromyalgia
Autism Spectrum
Marfan’s Syndrome
Mental Health
Seizures
Physical Disability
Stroke/TIA’s
Temporary Health Conditions
Uncontrolled HBP
Services
Examples of services available through DSPS that are over and above those regularly offered by the college would
be test-taking facilitation, assessment for learning disabilities, specialized counseling, interpreter services for
hearing-impaired or deaf students, mobility assistance, note taker services, reader services, transcription services,
specialized tutoring, access to adaptive equipment, job development/placement, registration assistance, special
parking and specialized instruction.
The Vocational Education Act identifies the following additional “disability” conditions for services to
students enrolled in eligible vocational programs:
Seriously emotionally disturbed, including mental or psychological impairments or chemical dependency.
Rev 6-14-2018
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