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
medical conditions.
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
your assistance.
Office of Student Life
Disability Services
Warner Center 226
1179 University Drive
Newark, Ohio 43055
740.366.9441 Phone
740.364.9646 Fax
(Please Print Legibly or Type)
First Name: ______________________ Middle: ____________ Last: _______________________________
Date of Birth: ___________________________ Last 4 digits of SSN: _______________________
Status (check one): current student transfer student prospective student
Local phone: (_______) - __________ - ____________ Cell phone: (_______) - __________ - __________
Street ________________________________________________________________________________
City, State, Zip __________________________________________________________________________
If COTC student, COTC E-mail ____________________________________________________@cotc.edu
Non-student E-mail address: _______________________________________________________________
Important: After documentation is reviewed, ODS will send an email notification to the student’s COTC
email account, (e.g. name-12345@cotc.edu), acknowledging receipt
of documentation and the eligibility status.
(Please Type or Print Legibly)
1. Date of Diagnosis: ___________________________________________________________________
2. Primary Diagnosis: __________________________________________________________________
Secondary Diagnosis: ________________________________________________________________
3. What is the severity of the disorder? Mild Moderate Severe
4. Please state the medication or treatment the student is currently prescribed:
5. Major Life Activities Assessment: Please check which of the following major life activities listed below
are affected because of the impairment. Indicate severity of limitations.
Life Activity Negligible Moderate Substantial Don’t Know
Social Interactions
Regular Class Attendance
Keeping appointments
Stress Management
Managing internal distractions
Managing external distractions
6. In addition to the major life activities affected that are indicated above, please describe any activities
that may be impacted by the disability or symptoms that may need to be addressed in the college
7. Please state specific recommendations regarding academic accommodations for this student:
8. Please add any additional comments that you feel are appropriate:
(Please sign & date below and completely fill in all other fields using TYPE or PRINT)
Provider Signature: _______________________________________ Date: ________________________
Provider Name (Print): ____________________________________________________________________
Title: ___________________________________________________________________________________
License or Certification #: _________________________________________________________________
Street ________________________________________________________________________________
City, State, Zip __________________________________________________________________________
Phone Number: (________) - _________ - _____________
FAX Number: (________) - _________ - _____________
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