Fillable Disability Verification Documentation Determination (Humboldt State University)

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Disability Verification Documentation Determination (Humboldt State University)

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One Harpst Street • Arcata, California 95521-8299 • 707.826.4678 • Fax 707.826.5397 • TDD 707.826.5392 • www.humboldt.edu/disability
THE CALIFORNIA STATE UNIVERSITY • Bakersfield • Channel Islands • Chico • Dominguez Hills • Fresno • Fullerton • Hayward • Humboldt • Long Beach • Los Angeles
Maritime Academy • Monterey Bay • Northridge • Pomona • Sacramento • San Bernardino • San Diego • San Francisco • San Jose • San Luis Obispo • San Marcos • Sonoma • Stanislaus
Student Disability Resource Center
Please submit Completed Form To:
Student Disability Resource Center
Humboldt State University
1 Harpst Street
Arcata, CA 95521
Phone: 707-826-4678 Fax: 707-826-5397
Please do not email confidential information
Disability Verification
Documentation Determination
The student named below may be eligible for academic accommodations provided through the Student Disability Resource Center at Humboldt State University. In
order to provide services, we must have a determination of a disability from his/her practitioner. Please be assured that the information provided by you will remain
confidential in SDRC and will not be released to other persons unless instructed to do so by the student.
Please note: Student medical records supplied to this office constitute "education records" under the Family Education and Privacy Act (FERPA) and as such, may be
reviewed by the student upon written request.
Section 1: Student Information (To be completed by student)
Name: HSU ID #:
Address: City: State:
Zip Code: Phone Number: HSU email:
Date:
I authorize the release of the information requested on this Disability Documentation Form to the Student Disability Resource Center, Humboldt State University.
Section 2: Diagnosis(es)
Page 1
Signature:
REMAINDER OF FORM TO BE COMPLETED BY PRACTITIONER
Feel free to attach additional information, documentation, and/or reports
Please describe the diagnosis(es). If appropriate, include the DSM diagnosis and information.
DIAGNOSIS 1:
Permanent Progressive
End Date:
Temporary
This diagnosis is considered:
End Date:
DIAGNOSIS 2:
End Date:
TemporaryProgressivePermanent
This diagnosis is considered:
DIAGNOSIS 3:
TemporaryProgressivePermanent
This diagnosis is considered:
Revised: 3/12/2014
One Harpst Street • Arcata, California 95521-8299 • 707.826.4678 • Fax 707.826.5397 • TDD 707.826.5392 • www.humboldt.edu/disability
THE CALIFORNIA STATE UNIVERSITY • Bakersfield • Channel Islands • Chico • Dominguez Hills • Fresno • Fullerton • Hayward • Humboldt • Long Beach • Los Angeles
Maritime Academy • Monterey Bay • Northridge • Pomona • Sacramento • San Bernardino • San Diego • San Francisco • San Jose • San Luis Obispo • San Marcos • Sonoma • Stanislaus
Section 3: Method(s) of Determining Diagnosis: (Please check all that apply)
Section 4: Disability-Related Effects on Academic Performance. (Please check all that apply)
Comprehensive Diagnostic Evaluation
(Neuro) Psychological Assessment
Consultation with Former Care Provider
Clinical Interview
Review of Medical Records
Other
Psychomotor Slowing
Intrusive Thoughts
Distractibility Impaired Memory
Agitation
Impulsivity
Impaired Judgment
Omissions
Inability to Focus
Impaired Motor Function
Inability to Sit for Extended Time
Other (Please
elaborate):
Please provide us with your recommendations for academic adjustments for this student:
Please provide additional information that will help us understand how this student's disability affects their academic performance:
Difficulty completing timed tasks due to:
Requires adaptive equipment to successfully perform routine tasks. Please specify:
Impaired Coordination
History of Impaired Performance
on Timed Tasks
Chronic Pain
Difficulty Sustaining Physical
Energy Over Extended Periods of
Time
Decreased Concentration
Confusion/Thought Disorder
Page 2
One Harpst Street • Arcata, California 95521-8299 • 707.826.4678 • Fax 707.826.5397 • TDD 707.826.5392 • www.humboldt.edu/disability
THE CALIFORNIA STATE UNIVERSITY • Bakersfield • Channel Islands • Chico • Dominguez Hills • Fresno • Fullerton • Hayward • Humboldt • Long Beach • Los Angeles
Maritime Academy • Monterey Bay • Northridge • Pomona • Sacramento • San Bernardino • San Diego • San Francisco • San Jose • San Luis Obispo • San Marcos • Sonoma • Stanislaus
Date:
Signature of Licensed Provider:
Type of License:
Fax Number:
State:City:
Phone Number:
License Number:
Zip Code:
Address:
Name:
Section 6: Licensed Practitioner:
Additional Comments:
Section 5: Medication-Related Functional Effects on Academic Performance
Functional limitations are substantial limitations in an individual's ability to perform a required major life activity as it relates to an educational setting (e.g. easily distracted,
poor concentration, difficulty focusing for extended periods of time, difficulty formulating and executing plan of action, difficulty overcoming unexpected obstacles, panics
in unfamiliar surroundings and situations, etc.)
Name of Drug with Dosage Purpose of Medication
Medications' Effects on Academic Performance
(Please check all that apply)
Confusion/Thought Disorder
Decreased Concentration
Impaired Coordination
Psychomotor Retardation
Sedation/Fatigue
Agitation
Distractibility
1. 1.
2.
3.
4.
2.
3.
4.
Other:
5. 5.
Page 3
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Disability Verification Documentation Determination (Humboldt State University)

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Completed 4 April 2021

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