Fillable Disability Documentation Form (Minneapolis Community and Technical College)

Fill Online, Printable, Fillable, Blank Disability Documentation Form (Minneapolis Community and Technical College) Form

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

Disability Documentation Form (Minneapolis Community and Technical College)

On average this form takes 8 minutes to complete

The Disability Documentation Form (Minneapolis Community and Technical College) form is 2 pages long and contains:

  • 0 signatures
  • 30 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Minneapolis Community and Technical College

BROWSE MINNEAPOLIS COMMUNITY AND TECHNICAL 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
 
Minneapolis College is an equal opportunity educator and employer. This document is available in alternative formats to individuals with disabilities by
calling Accessibility Resource Center at 612-659-6730 or by emailing accessibility@minneapolis.edu.
Disability Documentation Form
We welcome all forms of relevant documentation or information when working with a student to determine an
appropriate accommodation plan. To determine eligibility for services and/or accommodations, current and
comprehensive documentation regarding a physical or mental condition and its impact on the student’s function is
required from a licensed medical professional qualified to diagnose and treat the condition(s). See documentation
guidelines on page three of this document.
Student Information
Last Name First Name StarID
Diagnosis Information
Date of Diagnosis Most Recent Assessment Date
Diagnosis
The Diagnosis must clearly state a DSM-V Diagnosis and must verify interference with a major life activity. Please
select the major life activities affected by the diagnosis.
Caring for one’s self
Walking
Eating
Talking
Sleeping
Hearing
Concentrating
Listening
Memorizing
Speaking
Breathing
Organizing
Lifting
Social Interactions
Learning
Managing Stress
Seeing
Regular and timely attendance
Reading
Managing internal distractions
Writing
Managing external distractions
Standing
Performing Manual tasks
Thinking
Reaching/Grasping
Interacting with others
Making and keeping appointments
Sitting
Maintaining deadlines
Current Symptoms.
Current Treatment Strategies and Prognosis.
Summary of the functional limitations of the diagnosis and the impact of medication and/or treatment on educational
functioning.
Suggested Accommodations
Health Providers can provide suggestions for reasonable accommodations appropriate at the post-secondary level of
education. Such accommodations should be supported by the assessment results and by the diagnosis. The
Accessibility Resource Center will evaluate recommendations on a case-by-case basis. Accommodations must be
reasonable and cannot fundamentally alter the basic nature or essential elements of an institutions/s courses or
programs.
Provider’s Name Provider’s Title
Provider’s Credentials License# and State of Issue:
Business Phone Number Fax Number
Provider’s Signature Date of Report
Please fax this form to the Minneapolis College Accessibility Resource Center 612-659-6732
Disability Documentation Form | ARC 8/2020 Page 2
ARC Documentation Guidelines
Examples of Helpful Documentation or Information
Self-reporting the impact or barriers experienced due to disability is a vital part of the accommodation request process
and plan. The list below are examples of documentation to support or further inform about the student’s
accommodation needs.
• Educational records, such as the individualized education program (IEP), a 504 Plan, etc.
• Neuropsychological or educational evaluation
• Medical records
• Statement or report from a health, mental health, or other service provider
• Audiology report
• Vision assessment
Information for Health, Mental Health or Other Service Providers
A statement or summary that includes any of the following information will assist us in determining an
accommodation plan.
• The current disability and the history of diagnosis (include relevant information about how the diagnosis was
determined and date of onset or date of diagnosis)
• Anticipated prognosis (if applicable)
• Specific symptoms, including frequency and severity
• The current treatment plan (if relevant to accommodation planning)
• The extent of impact of the disability on major life activities (such as communicating, reading, writing,
learning, working, walking, eating, breathing, etc.)
• Any recommendations or strategies that would reduce the impact of the disability (including any relevant
history of accommodations used in the past).
Along with the statement, the certifying professional must include:
• Name and Title
• Address
• Daytime Phone Number
• Fax Number
• Type of specialty or license
• License # and State where the license was issued
• Signature and Date of Report
Disability Documentation Form | ARC 8/2020 Page 3
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

Disability Documentation Form (Minneapolis Community and Technical 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 3 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document