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Disability Support Services (Montana State University - Billings)

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Disability Support Services Page 1 of 3 Updated 08/28/2019
Disability Support Services
University Campus
College of Education Rm 135
1500 University Dr.
Billings, MT 59101
(406) 657-2283
FAX (406) 657-1658
City College
Tech. Building, Rm 016A
3803 Central Av.
Billings, MT 59102
(406)247-3029
FAX (406) 247-3014
Disability Verification
The student named below has identified you as a licensed professional who is familiar with him/her. Please assist
us in providing appropriate educational services for this student by verifying his/her diagnosis (diagnoses). In
addition, please tell us how the student’s disability may affect his/her ability to function in an academic environment
and any accommodations that you believe will assist the student in the tasks of learning.
Release of information, to be completed by the student (please print legibly in ink):
Student’s Name: __________________ , ____________________ ________________
Last First Middle Date of Birth
I Authorize the release of information requested below to Disability Support Services at
Montana State University Billings. (Your evaluator may have additional releases for you to sign.)
____________________________________________________ ____________
Student’s Release Signature Date
To be completed by a licensed/certified professional (Please use additional pages as needed)
1. Diagnoses:
2. Duration
☐ ☐
Permanent Temporary
☐ ☐
Permanent Temporary
Expected duration of temporary
disability. ______________________
Expected duration of temporary
disability. ______________________
3. Level of
Severity:
☐ ☐ ☐ ☐
Mild Moderate Severe Partial
Remission
☐ ☐ ☐ ☐
Mild Moderate Severe Partial
Remission
4. Dates of
Diagnoses:
5. Dates of last
office visits:
Mobility Limitation
6. Does the student use a wheelchair?
☐ ☐ ☐ Other:
No Yes, Powered Yes, Non-powered _____________
Disability Support Services Page 2 of 3 Updated 08/28/2019
To be completed by a licensed/certified professional (continued)
Mobility Limitation (continued)
Recommended accommodations:
Visual Impairment
Left Right
7. Diagnoses:
a. Acuity
b. Field
Recommended accommodations:
Hearing Impairment: Please include a current audiological report.
Left Right
8. Diagnoses:
a. DB Loss
b. Hearing Aids
9. Ability to Sign?
Expert Good Fair Poor None I don’t know
Recommended accommodations:
-
-
Disability Support Services Page 3 of 3 Updated 08/28/2019
To be completed by a licensed/certified professional (continued)
10. How does the student’s disability substantially limit his/her ability to function in an academic environment
(i.e. mobility, attendance, classroom activities, test taking, etc.)?
11. Suggested accommodations:
12. Additional comments:
I certify that the above referenced client/patient has a “physical or mental impairment that substantially
limits one or more major life activities of such individual” as defined by the Americans with Disabilities
Act.
In addition, I have the necessary professional qualifications to document my client/patient’s disability,
and the information provided on this form is accurate to the best of my knowledge
______________________________________________________________________
Name of professional please print
_______________________________________________ _____________________
Signature of professional Date
Professional Credential _ _____________________________ _____________________
License/Certification #
_________________________________________ _________ ____ ___________
Street Address City State Zip
Please return this form as soon as possible so this student may receive accommodations.
Please include the necessary verifying documents from your files.
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Disability Support Services (Montana State University - Billings)

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Completed 24 August 2020

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