Disability Verification Form
The Office for Disability Services (ODS) provides academic services and accommodations for
students with diagnosed disabilities. The documentation provided regarding the disability diagnosis
must demonstrate a disability covered under Section 504 of the Rehabilitation Act of 1973 and Title II
of the Americans with Disabilities Act (ADA) of 1990. The ADA defines a disability as a physical or
mental impairment that substantially limits one or more major life activities.
The outline below has been developed to assist the student in working with the treating or diagnosing
healthcare professional (psychiatrist, psychologist, counselor, therapist, social worker, medical
doctor, optometrists, speech-language pathologists etc.) in obtaining the specific information to
evaluate eligibility for academic accommodations.
A. The healthcare professional(s) conducting the assessment and/or making the diagnosis
must be qualified to do so. These persons are generally trained, certified, or licensed to diagnosis
B. All parts of the form must be completed as thoroughly as possible. Inadequate information,
incomplete answers and/or illegible handwriting will delay the eligibility review process by
necessitating follow up contact for clarification. It is recommended that this form be completed by
typing the information into the editable PDF version of the form available on our website
C. The healthcare provider should attach any reports which provide additional related
information (e.g. psycho-educational testing, neuropsychological test results, etc.). If a
comprehensive diagnostic report is available that provides the requested information, copies of that
report can be submitted for documentation instead of this form.
D. The information you provide will be kept in the student’s file at ODS, where it will be held
strictly confidential. This form may be released to the student at his/her request. In addition to the
requested information, please attach any other information you think would be relevant to the
student’s academic adjustment.
If you have questions regarding this form, please call the ODS office at 740.366.9441. Thank you for
Office of Student Life
Warner Center 226
1179 University Drive
Newark, Ohio 43055