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LEARNING ACCOMMODATIONS CENTER
www.necc.mass.edu/learningaccommodations
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
prognosis.
4. Please list all current medications and side effects that could potentially impact academic performance.
12/2019
