Revised 9-25-2014
Disabled Students Programs & Services
DISABILITY VERIFICATION FORM
PLEASE RETURN TO DSPS
951-639-5305 (MVC) or 951-487-3305 (SJC)
The student named below may be eligible for special services at this college. In order to provide services we must have a
verification of disability/diagnosis. The information you provide will be used for the sole purpose of determining
eligibility for and authorization of accommodations at Mt. San Jacinto Community College.
Name: Date of Birth:
Phone Number: Student ID#:
Please provide the following information IN FULL in order to help us determine reasonable educational
accommodations to support this student:
Diagnosis:
If applicable, DSM Code and severity:
Duration of condition
Permanente/Chronic Temporary, End Date (Required):
Conditions
Mild Moderate Severe
Prescribed medication(s) dosage and side effects:
Functional limitations of conditions and/or medication (e.g. the ways in which the diagnosis and/or side effects of
medications affect the student.) Please check:
Speaking Hearing Loss Processing Oral Material
Limited Ambulation Taking Class Notes Processing Visual Material
Visual Acuity Poor Concentration Slow Processing of Information
Other:
DSPS professional staff, with consultation by the DSPS Director, may, through personal observation, verify the existence
of an observable disability:
DSPS Staff Signature: Date:
I understand that the information provided in this form will become part of the student record subject to the Federal
Family Education Rights and Privacy Act (FERPA) of 1974 and may be released to the student upon student request.
Signature:
Verifying Licensed Professional Title/License # Date
Name (Print):
Address:
Phone: Fax:
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