Fillable Disability Verification (Mission College)

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Disability Verification (Mission College)

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MISSION COLLEGE D.S.P.S.
DISABILITY VERIFICATION BY OUTSIDE RESOURCE
Name I.D. #
Date of Birth
Street Address
Home Phone Number
Cell Phone Number
The following information is required and must be filled out in full.
Prone to exacerbation
Estimated Duration
Name of Licensed or Certified Professional
Address, City & Zip code
Name
THIS SECTION MUST BE COMPLETED BY THE STUDENT
Email Address
In order to receive disability-related services at Mission College, a verification of disability must be provided.
DIAGNOSIS
DSM IV CODE
SEVERITY (if applicable)
Stable
* Please Fax, Email, or Mail this form and attached Educational, Medical and/or Psychological documentation to:
Cell Phone Number
I request that the professional designated below complete this form.
Phone Number
Fax Number
THIS SECTION MUST BE COMPLETED BY THE LICENSED OR CERTIFIED PROFESSIONAL
Please describe how this condition substantially
limits MAJOR life activities:
CONDITION IS:
Duration of Disability
Permanent/Chronic
Temporary
I understand that the information provided by the verifying professional will become part
of the student record and may be released to the student upon their written request.
Verifying Professional Signature
Date
If the information above is completed by someone other than the professional who made the diagnosis,
please provide the name and address of the person who made the diagnosis in the space provided below.
Address, City & Zip code
Mission College Disability Support Programs and Services
3000 Mission College Blvd. Mailstop #22
Santa Clara, CA 95054
Phone (408) 855-5085
Fax (408) 855-5449
Email: dsps@wvm.edu
License Number
Print Form
Administrative Code, Title V, identifies the following qualifying disabilities:
I. PHYSICAL DISABILITY: a visual, mobility, orthopedic or other health impairment.
A. Visual impairment means a total or partial loss of sight.
B. Mobility and Orthopedic disability means a serious limitation in ambulatory or motor functions.
II. COMMUNICATION DISABILITY: an impairment in the process of speech, language or hearing.
A. Hearing impairment means a total or partial loss of hearing function which impedes the
communication process essential to language, educational, social and/or cultural interaction.
B. Speech and language impairments mean one or more speech/language disorders of voice,
articulation, rhythm and/or the receptive and expressive processes of language.
III.
LEARNING DISABILITY: a persistent condition of presumed neurological dysfunction which may exist
with other disabling conditions. This dysfunction continues despite instruction in standard classroom situations.
To be categorized as Learning Disabled, a student must exhibit:
A. Average to above average intellectual ability.
B. Severe processing deficit(s).
C. Severe aptitude-achievement discrepancy(ies).
D. Measured achievement in an instructional or employment setting.
IV.
ACQUIRED BRAIN IMPAIRMENT: a verified deficit in brain function which results in a total or partial
loss of cognitive, communication, motor, psychosocial and/or sensory perceptual abilities.
V.
DEVLOPMENTALLY DELAYED LEARNER: a student who exhibits the following:
A. Below average intellectual functioning, and
B. Potential for measurable achievement in instructional/employment setting.
VI.
PSYCHOLOGICAL DISABILITY: a persistent psychological or psychiatric disorder,
or emotional or mental illness.
A. For the purposes of this subchapter, the following are not psychological disabilities:
1. Transvestitism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders
not resulting from physical impairments, or other sexual behavior disorders.
2. Compulsive gaming, kleptomania or pyromania, and
3. Psychoactive substance abuse disorders resulting from current illegal drug use.
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Disability Verification (Mission College)

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Completed 23 July 2020

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