Fillable Disability Verification Form (Columbus State Community College)

Fill Online, Printable, Fillable, Blank Disability Verification Form (Columbus State Community College) Form

Use Fill to complete blank online COLUMBUS STATE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Disability Verification Form (Columbus State Community College)

On average this form takes 11 minutes to complete

The Disability Verification Form (Columbus State Community College) form is 2 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Columbus State Community College

BROWSE COLUMBUS STATE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Disability Verification Form
Part I – To be completed and signed by the student:
Name:
Date of Birth:
Address:
City, State, Zip:
Student ID:
Phone Number:
Email:
I hereby authorize ______________________________________ to release/discuss the information below.
Signa
ture of Student:
___________________________________ Date: _____________________________
Provider – Please Read
Purpose of Disability Verification:
Disability Services at Columbus State Community College (CSCC) provides academic accommodations for
students with documented disabilities. This completed verification form should provide enough information to
verify the student has a disability as defined by Section 504 of the Rehabilitation Act, and the Americans with
Disabilities Act. The form must be completed by a licensed professional (e.g. physician, psychologist, licensed
social worker etc.) This form is not sufficient to document a learning disability.
Part II. To Be Completed by the Provider
1. Diagnostic Information (including DSM V diagnosis if applicable)
2. Current Medication and Side Effects:
(Continued on 2
nd
page)
click to sign
signature
click to edit
3. Please describe the impact of the student’s disability in the educational environment.
4. Impact of Disability on Major Life Activities
Please indicate any major life activities substantially limited by the student’s disability with an X
Activity:
Impact?
Activity:
Concentrating
Organization
Reading
Social Interactions
Written expression
Self-care
Math
Sleeping
Stress management
Manual Dexterity
Managing distractions
Vision
Regular class attendance
Hearing
Time management
5. Additional Information if available
Please attach any additional documentation that you believe to be relevant (e.g., psychological assessment,
neuropsychological evaluation, diagnostic testing, etc.).
Provider Credentials:
Print Name and Title:
Date Completed:
License #:
Agency Name:
Address:
City/State/Zip:
Phone:
Signature:
Return form to:
Disability Services
Columbus State Community College
550 East Spring St.
Columbus, OH 43216
Phone: (614) 287-2570
Fax: (614) 287-6054
Email: dsdocumentation@cscc.edu
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Disability Verification Form (Columbus State Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document