100 Elliott Street, Haverhill, MA 01830 Behrakis One-Stop Student Services Center, SC111
Tel: 978-556-3654 Fax: 978-556-3168 email: lacenter@necc.mass.edu
Disability Verification Form
Name of NECC Student: D.O.B.
The above named individual is applying for services from the Learning Accommodations Center. In
order to provide equal access, the Learning Accommodations Center provides services, accommodations and
support to students with documented disabilities in accordance with applicable state and federal laws. Students
are required to provide current documentation of their disability. Please complete the form below to assist us in
determining this student’s eligibility for reasonable accommodations. We may need to contact your office for
more information to help us determine accommodations for this student.
Please note: This form can only be filled out by someone who has a professional relationship with this
student, is a treating clinician, and qualified to make the diagnoses below. This could include a
Physician, Nurse Practitioner, Psychologist, Psychiatrist, Neuropsychologist, Licensed Clinical Social
Worker, Licensed Mental Health Counselor or other relevantly trained and licensed professional.
Disability documents are kept as part of the student’s confidential file in the Learning Accommodations Center.
Please Note: Students may request a copy of this document.
1. Statement of Diagnosis or Diagnoses
Primary: Length of Time expected to have this Diagnosis:
Secondary: Length of Time expected to have this Diagnosis:
Other: Length of Time expected to have this Diagnosis:
2. Summary of assessment procedures/evaluations used to make the diagnosis(es) and evaluation results.
3. Summary of current symptoms including nature, frequency, severity, known triggers, progression, and
4. Please list all current medications and side effects that could potentially impact academic performance.
5. Specify the current functional limitations (physical, cognitive, learning, behavioral, and social).
6. What is the disability’s current impact on this student’s functioning in an educational setting? What type of
functional limitations may affect academic performance or accessibility? Please be as specific as possible.
7. In your professional opinion, does this student require accommodations in order to be provided with equal
access? If so, what accommodations would you suggest to address this student’s functional limitations? (We
make the final decision). See attached page for examples of accommodations used by college students.
Accommodations Needed
Functional Limitations To Be Accommodated
8. What are this student’s strengths and what compensatory strategies does the student use that are beneficial?
9. Additional Comments:
Please sign and date below, indicate title and credentials, and provide contact information. Please print legibly.
Signature Title/Credentials/License# Date
Print Name
Phone #
Fax #
click to sign
click to edit
Behrakis One-Stop Student Services Center, SC111
100 Elliott Street, Haverhill, MA 01830
Tel: 978
-556-3654 Fax: 978-556-3168 email: lacenter@necc.mass.edu
Examples of Accommodations Available to Colle
ge Students
Each student’s individual needs are evaluated based on the documentation provided. (We make the final
Assistive Technology:
Computer with word processing software
Alternative format textbooks
Text to Speech software
Voice Recognition software
Magnification devices and software
Enlarged materials
Extended testing time
Note taker
Preferential seating
Recorded lectures
Reduced Course load
Reduced distractions testing environment
Specialized furniture i.e. desks, chairs
Visual assistant