Verification Form
Cognitive Impairments
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Cognitive Impairments to obtain
current information from a qualified practitioner (e.g., licensed medical practitioner, psychologist, psychiatrist, neuropsychologist)
regarding a student’s cognitive impairment symptoms and their impact on the student and his or her need for accommodations. This
Verification Form should 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 Cognitive Impairments.
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 cognitive impairments is as follows:
1.
Persistent learning difficulties, memory challenges, inability to maintain attention, deficits of self-regulation, inability to process
information verbally and visually, low IQ score, and academic performance below expectations as measured by objective and
statistically sound assessments of aptitude and achievement
2.
History of learning difficulties, memory challenges, inability to maintain attention, deficits of self-regulation, inability to process
information verbally and visually, low IQ score, and academic performance
3.
Functional limitations affecting an important life skill, including academic functioning
4.
Exclusion of alternative diagnoses or attributing factors
5.
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: Zip:
(If different from Permanent Street Address)
Local 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 history of a cognitive disorder? YES
NO
Approximately at what age or grade did the student start to exhibit cognitive deficits
or was assessed for a cognitive disorder?
What date was the student diagnosed with cognitive impairment
symptoms?
Month Year
Adapted by permission from The Pennsylvania State University
