Fillable Disability-verification Las Positas College

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Disability-verification Las Positas College

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Disabled Student Programs & Services
3000 Campus Hill Drive | Room 1615, Livermore, CA 94551
(OVER )
DISABILITY VERIFICATION
In order to receive disability-related services at Las Positas College, students are required to provide
documentation of their disability.
Student Information
Student Name: W#: _______________________________
Date of Birth: Phone:
Mailing Address:
City: State: Zip Code:
Student Signature: ________________________________________ Date: _________________
To Be Completed by Licensed Professional
Please provide the following information in full in order to help us determine reasonable educational
accommodations to support this student. Please complete both sides.
1. Primary Diagnosis: ______________________________________________________________________
If applicable, DSM IV Code and Severity: __________________________________________________
2. Duration of Condition.
Permanent/Chronic If temporary, give estimated duration________________________________
3. Condition is:
Stable Observable Prone to exacerbations Non-observable
4. Prescribed Medication(s), Dosage and Side effects: ____________________________________________
______________________________________________________________________________________
5. Functional limitations of condition and/or medication (e.g. the ways in which the diagnosis and/or side
effects of medications affect the student in the educational setting.) Please check:
Speaking Hearing loss Visual acuity Limited ambulation
Taking class notes Processing visual materials Providing written assignments
Easily distracted Processing oral material Slow processing of information
Poor concentration Caring for self
Other: ______________________________________________________________________________
______________________________________________________________________________________
1. Secondary Diagnosis: _____________________________________________________________________
If applicable, DSM IV Code and Severity: __________________________________________________
2. Duration of Condition.
Permanent/Chronic If temporary, give estimated duration________________________________
3. Condition is:
Stable Observable Prone to exacerbations Non-observable
4. Prescribed Medication(s), Dosage and Side effects: ____________________________________________
______________________________________________________________________________________
5. Functional limitations of condition and/or medication (e.g. the ways in which the diagnosis and/or side
effects of medications affect the student in the educational setting.) Please check:
Speaking Hearing loss Visual acuity Limited ambulation
Taking class notes Processing visual materials Providing written assignments
Easily distracted Processing oral material Slow processing of information
Poor concentration Caring for self
Other: ______________________________________________________________________________
______________________________________________________________________________________
I understand that the information provided with this form will become part of the student record subject to
the Federal Family Education Rights and Private Act of 1974 and may be released to the student upon their
written request.
Name of Licensed or Certified Professional:
Address: _______________________________________________________________________________
City: ___________________________________________ State: ___________ Zip: _______________
Phone: _____________________________________ Fax: ______________________________________
Signature: ________________________________________________ Date: ________________________
IMPORTANT: For questions about this form, please contact the Disabled Student Programs & Services
(DSPS) office at 925.424.1510. Once completed, please scan and email it to
lpc-dsps@laspositascollege.edu or fax it to 925.424.1515.
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Disability-verification Las Positas College

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Completed 17 November 2019

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