Fillable Form 1.: Verification Form Attention Deficit Hyperactivity Disorder (Bucks County Community College)

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Form 1.: Verification Form Attention Deficit Hyperactivity Disorder (Bucks County Community College)

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Verification Form
Attention Deficit Hyperactivity Disorder
Bucks County Community College’s Accessi
bility Office (TAO) has established the Verification Form for Attention Deficit Hyperactivity
Disorder (ADHD) to obtain current information from a licensed medical practitioner regarding a student’s mobility or upper extremity
impairment and its impact on the student and his or her need for accommodations. This Verification Form may supplement
information that is provided in other reports, including medical reports, physiological assessments, or secondary school
documentation. Any documentation, including this Verification Form, must meet Bucks County Community College’s TAO guidelines
for ADHD.
The person completing this form (after Section II) may not be a relative of the student or hold power of attorney
over the student.
A summary of the guideline criteria for documenting ADHD is as follows:
1.
A clinical history of ADD or ADHD
2.
Symptoms of inattentiveness and/or impulsivity/ hyperactivity determined through the administration of objective
measurements of attention and/or ADD or ADHD Rating Scales or Checklists
3.
Functional impairment in one or more settings, including educational
4.
Functional limitations affecting some important life skills, including academic functioning
5.
Exclusion of alternative diagnoses and
6.
Summary and recommendations
Section I: Student Information (Please type information or print legibly)
Student Name:
Last
First
Middle
Student ID:
Date of Birth:
Cell Phone:
Home Phone:
Bucks Email:
Home Email:
Permanent Street
Address:
City:
State:
(If different from Permanent Street Address)
Local Street
Address:
City:
State:
Section II: Provider Section (Please type information or print legibly)
A. Contact with the Student:
Date of initial contact with the student:
Date of last contact with the student:
B. Diagnosis Information:
1. Clinical History
Does the student have a clinical history (i.e., prior to age 12) of ADD or ADHD symptoms?
YES
NO
Approximately at what age did the student start to exhibit ADD or ADHD symptoms?
What date was the student diagnosed with ADD or ADHD symptoms?
Month
Year
Adapted by permission from The Pennsylvania State University
________________________________________________
Verification Form: Attention Deficit Hyperactivity Disorder
2. Current Symptoms
a. Please check all ADHD symptoms that the student currently exhibits:
Inattention:
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has difficulty sustaining attention in tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
(e.g., loses focus, side-tracked).
Often has difficulty organizing tasks and activities.
Often avoids, dislikes, or is reluctant to engage in tasks (such as schoolwork or homework) that require sustained
mental effort.
Often loses things necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted by extraneous stimuli.
Is often forgetful in daily activities.
Hyperactivity:
Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves (or greatly feels the need to leave) seat in classroom or in other situations in which remaining seated
is expected.
Often runs about or climbs excessively in situations in which it is inappropriate (adolescents or adults may be
limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often “on the go” or often acts as if “driven by a motor.”
Often talks excessively.
Impulsiveness:
Often blurts out answers before questions have been completed.
Often has difficulty awaiting turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).
b. Is there clear evidence that the student’s ADHD symptoms are present in one or more setting including the
educational environment?
School (classroom or
educational setting):
Home or work:
With friends or
relatives:
In other activities:
c. Is there clear evidence that the student’s ADHD symptoms are present in one or more setting including the
educational environment?
School functioning:
Social functioning:
Work functioning:
2
Verification Form: Attention Deficit Hyperactivity Disorder
d. Did you use an objective measure of attention and/or a subjective ADHD Rating Scale
or Checklist to obtain information about the student’s symptoms and functioning in
various settings?
YES
NO
1) If yes, which objective ADHD measurement and/or subjective ADHD Rating Scale(s) or Checklist(s) did
you use?
2) If no, how did you reach your conclusion about the ADHD diagnosis and treatment?
3. ICD 10 Codes:
Please check the student’s ICD 10 Code for ADHD Type
F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2 Attention-deficit hyperactivity disorder, combined type
F90.8
Attention-deficit hyperactivity disorder, other type
F90.9 Attention-deficit hyperactivity disorder, unspecified type
4. World Health Organization Disability Assessment Schedule 2.0
a. Does the student have a WHODAS 2 Score?
YES
NO
b. If yes, please provide the score here:
5. Other Diagnosis and Student Behavioral History
a. Does the student have any other diagnosis?
YES
NO
b. If yes, please list the ICD 10 Codes and the diagnosis in the space provided below:
ICD 10 Code:
Diagnosis
c.
Does the student have a clinical history of hospitalizations related to the diagnosed
psychological disorder?
YES
NO
Number of times student was hospitalized:
1) Please provide information regarding the student’s history of hospitalization(s).
d.
Does the student have a clinical history of verbal or physical aggression toward
peers, family members or adults?
YES
NO
1) Please provide information regarding the student’s history of verbal or physical aggression.
3
Verification Form: Attention Deficit Hyperactivity Disorder
e.
Does the student have a clinical history of suicidal ideation or has the student
attempted to take their own life?
YES
NO
1)
Number of times student threatened suicide or has reported
suicidal ideation:
2)
Number of times student attempted suicide:
3) Please provide
information regarding the student’s history of suicidal ideation or suicide attempt(s).
6. Military Service
a. Has the student served in the military?
YES
NO
1) What branch of the military did the student serve with?
United States Air Force
United States Coast Guard
United States Navy
United States Army
United States Marine Corp.
b. Is the diagnosis related to their service in the military?
YES
NO
c. Is the receiving treatment through United States Department of Veterans Affairs?
YES
NO
1) Please provide information regarding the student’s history of psychological needs related to their military
service.
1)
At what location of the VA does the student receive services?
C. Family History:
1. Does the student have a family history of physical health impairments?
YES
NO
2. If yes, please check all that apply:
Mother
Father
Siblings
Grandparents (Maternal)
Grandparents (Paternal)
Aunts (Maternal)
Uncles (Maternal)
Aunts (Paternal)
Uncles (Paternal)
Cousins (Maternal)
Cousins (Paternal)
a. If yes, please list the family history of any health disorders.
4
Verification Form: Attention Deficit Hyperactivity Disorder
3. Does the student have a family history of any psychological disorders?
YES
NO
4. If yes, please check all that apply:
Mother
Father
Siblings
Grandparents (Maternal)
Grandparents (Paternal)
Aunts (Maternal)
Uncles (Maternal)
Aunts (Paternal)
Uncles (Paternal)
Cousins (Maternal)
Cousins (Paternal)
a. If yes, please list the family history of any psychological disorders.
D. Educational History:
1. Did the student receive special education or intervention services at the K-12 level?
YES
NO
2. If yes, please check all that apply:
Response to Intervention (RTI) Level 1
504 Plan
Response to Intervention (RTI) Level 2
Other:
Response to Intervention (RTI) Level 3
Other:
Individualized Education Program (IEP)
Other:
3. Did the student have a modified curriculum at the K-12 level?
* A modified curriculum means that the student had alternative or different exams and assignments than their peers.
YES
NO
E. Assistive Technology and Durable Medical Equipment:
1. Does the student use assistive technology?
YES
NO
a. If yes, please list the assistive technology.
2. Does the student use durable medical equipment?
YES
NO
a. If yes, please list the durable medical equipment.
5
Verification Form: Attention Deficit Hyperactivity Disorder
D. Medication(s):
1. Is the student currently taking medication(s) for any symptoms related to the diagnosis?
YES
NO
2. Does the student have a history of noncompliance with medication?
YES
NO
a. If yes, please list the behaviors or incidents of noncompliance with medication in the student’s history.
3. If yes, please provide information below for each medication the student is currently prescribed:
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication • Dosage • Frequency
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
6
Verification Form: Attention Deficit Hyperactivity Disorder
E. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current ADHD symptoms and then indicate what reasonable academic accommodations
would mitigate the symptom listed.
2. Sample:
Symptom: (Example)
Student has difficulty focusing on lectures and does not gain most information when taking notes.
Recommended Reasonable Accommodation(s):
Student will need assistance with notetaking. Student would benefit from the use of a LiveScribe pen, audio
recording lectures or from receiving instructor notes.
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
7
Verification Form: Attention Deficit Hyperactivity Disorder
Section III: Provider’s Certifying Professional Information
(Please type information or print legibly)
Professionals conducting the assessment, rendering a diagnosis, and providing recommendations for reasonable
accommodations must be qualified to do so (e.g., licensed physician, psychiatrist, clinical psychologist). The provider signing this
form must be the same person answering the above questions. The person completing this form may not be a relative of the
student or hold power of attorney over the student.
Provider Name:
Last
First
Middle
Credentials:
License Number:
State of Licenser:
Office Phone:
Office Fax:
Office Email:
Office Website:
Office Street
Address:
City:
State:
Provider Signature:
Date:
Section IV: Submitting This Form
It is the responsibility of the student to submit this form to the Learning Specialist in the Accessibility Office (TAO) at
Bucks County Community College during their intake appointment when they register with TAO. Students will also be
required to meet with a Learning Specialist if they would like to update their accommodations using the verification
form or any other form of documentation.
Section V: How to Make an Intake Appointment
Students are encouraged to call or email the Accessibility Office (TAO) to schedule an appointment. Intake appointments
are only done in person. There are certain times of year that appointment waiting times can be up to six weeks. The
student identification number and Bucks email is required for students to obtain an intake appointment. Students are
encouraged to contact TAO as soon as possible to ensure that their accommodations are approved and put into place as
soon as possible. TAO’s contact information is as follows:
Phone: (215) 968-8182
Email: accessibility@bucks.edu
Office: Bucks County Community College
275 Swamp Road
Rollins Center • Student Services Office • Room 001
Newtown, Pennsylvania 18940
Appointments can be scheduled for the Upper Bucks (Perkasie) and Lower Bucks (Bristol) campuses. TAO Learning
Specialists are on each of the satellite campuses one day per week. The student should inform the TAO team member if
they have a campus preference.
Information regarding the Accessibility Office (TAO), accommodations and assistive technology (AT) at Bucks County
Community College can be found at https://www.bucks.edu/resources/campusresources/accessibility/
. Please visit our
website for the latest information and updates as they are made available. If you have any questions, please feel free to
call us (215) 968-8182.
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Form 1.: Verification Form Attention Deficit Hyperactivity Disorder (Bucks County Community College)

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Completed 3 October 2020

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