Fillable Form 1.: Verification Form Autism Spectrum Disorder Bucks (Bucks County Community College)

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Form 1.: Verification Form Autism Spectrum Disorder Bucks (Bucks County Community College)

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Verification Form
Autism Spectrum Disorder
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Autism Spectrum Disorder (ASD)
to obtain current information from a qualified practitioner (e.g., physician, psychiatrist, psychologist) regarding a student’s ASD
symptoms, related medications, and their impact on the student and his or her need for accommodations in the higher education
classroom setting. This Verification Form may supplement information that is provided in other reports, including full
neuropsychological or psychoeducational evaluations or secondary school documentation. Any documentation, including this
Verification Form, must meet Bucks County Community College’s TAO guidelines for ASD. The person completing this form may not
be a relative of the student or hold power of attorney over the student.
The person completing this form may not be a relative of the student or hold power of attorney over the student.
A summary of the guideline criteria for documenting ASD is as follows:
1.
A clinical history of ASD
2.
Symptoms involving social interaction and nonverbal communication, sensitivity to sensory input, fixated interests, and/or
repetitive behaviors and adherence to routines determined through the administration of autism-specific behavioral evaluations
3.
Functional limitations affecting an important life skill (academic, social, or occupational)
4.
Assessment of global intellectual functioning and current academic functioning as measured by aptitude and achievement tests
respectively
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:
City:
State:
Zip:
(If different from Permanent Street Address)
City:
State:
Zip:
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 ASD symptoms?
YES
NO
Approximately at what age did the student start to exhibit ASD symptoms?
What date was the student diagnosed with ASD symptoms?
Month
Year
Adapted by permission from The Pennsylvania State University
Verification Form: Autism Spectrum Disorder
2. Current Symptoms
a. Please provide information regarding the student’s current presenting symptoms:
Social interaction, reciprocal verbal
communication, shared emotions and affect:
Nonverbal communication:
Hyper or hypo sensitivity to sensory input:
Fixated interests:
Repetitive behaviors and/or adherence to
routines:
Black and white thinking or rigidity in
following rules:
b. What is the severity of the disorder with regard to social impairments and rituals and repetitive behaviors
based on the DSM-V severity rating scale?
Social Communication:
Restricted Interests & Repetitive Behaviors:
Requiring support (Level 1)
Requiring support (Level 1)
Requiring substantial support (Level 2)
Requiring substantial support (Level 2)
Requiring very substantial support (Level 3)
Requiring very substantial support (Level 3)
c. Is there clear evidence that the student’s ASD symptoms are present in one or more setting including the
educational environment?
School functioning:
Social functioning:
Work functioning:
d. Did you use an ASD-specific behavioral evaluation and/or ASD rating scale or checklist
to obtain information about the student’s symptoms and functioning in various
settings?
YES
NO
1) If yes, which ASD behavioral evaluation and/or rating scale(s) or checklist(s) did you use?
2
Verification Form: Autism Spectrum Disorder
2) If no, how did you reach your conclusion about the ASD diagnosis and treatment?
e. Please provide information regarding the student’s global intellectual functioning and current academic
functioning as measured by aptitude and achievement tests respectively.
(Please note that a neuropsychological
or psychoeducational evaluative report containing this information can supplement this Verification Form).
1) Is this information contained within an accompanying evaluative report?
YES
NO
2) Aptitude: List (a) the name of the comprehensive and current aptitude/cognitive instrument
administered; (b) the standard scores per subtest; and (c) the percentiles per subtest.
3) Achievement: List (a) the name of the comprehensive and current achievement battery administered;
(b) the standard scores per academic area subtest; and (c) the percentiles per academic area subtest.
3. ICD 10 Codes:
Please check the student’s ICD 10 Code for ASD Type(s)
F84.0 Autistic disorder
F84.5 Asperger's syndrome
F84.8 Other pervasive developmental disorders
F84.9 Pervasive developmental disorder, unspecified
4. Behavioral Information:
a.
Does the student have a clinical history of alcohol abuse?
YES
NO
1) Please provide information regarding the student’s history of alcohol abuse.
b. Does the student have a clinical history of drug abuse?
YES
NO
1) Please provide information regarding the student’s history of drug abuse.
c.
Does the student have a clinical history of verbal or physical aggression toward
YES
NO
peers, family members or adults?
1) Please provide information regarding the student’s history of verbal or physical aggression.
5. 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.
3
Verification Form: Autism Spectrum Disorder
b. Is the diagnosis related to their service in the military?
YES
NO
1) Please provide information regarding the student’s history of physical health needs related to their
military service.
c. Is the receiving treatment through United States Department of Veterans Affairs?
YES
NO
1)
At what location of the VA does the student receive services?
6. 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:
7. Other Diagnosis and ICD 10 Codes?
a. Does the student have any other diagnosis?
YES
NO
b. If yes, please list the DSM-V 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 a diagnosed
YES
NO
psychological disorder?
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 suicidal ideation or has the student
YES
NO
attempted to take their own life?
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).
4
Verification Form: Autism Spectrum Disorder
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.
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?
YES
NO
* A modified curriculum means that the student had alternative or different exams and assignments than their peers.
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: Autism Spectrum 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 (e.g., Fluoxetine (Prozac) 20 mg 1 x daily):
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: Autism Spectrum Disorder
E. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current ASD symptoms and then indicate what reasonable academic accommodations
would mitigate the symptom listed.
2. Sample:
Symptom: (Example)
Difficulty tolerating distractions (i.e., low tolerance for noise)
Recommended Reasonable Accommodation(s):
Student should be provided a testing environment that limits distractions during tests, exams or quizzes.
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: Autism Spectrum 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.
Provider Name:
Last
First
Middle
Credentials:
License Number:
State of Licenser:
Office Phone:
Office Fax:
Office Email:
Office Website:
Office Street
Address:
City:
State:
Zip:
Provider Signature:
Date:
Section IV: Submitting This Form
It is the responsibility of the student to submit the form to the Accessibility Office (TAO) at Bucks County Community
College
where the student is enrolled. The student will submit the form to the Learning Specialist 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.
8
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Form 1.: Verification Form Autism Spectrum Disorder Bucks (Bucks County Community College)

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Completed 3 October 2020

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