Fillable Form 44691: Disability Verification Form The Office for (Ohio State University Agricultural Technical Institute)

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Form 44691: Disability Verification Form The Office for (Ohio State University Agricultural Technical Institute)

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The Form 44691: Disability Verification Form The Office for (Ohio State University Agricultural Technical Institute) form is 4 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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Updated 04-2020
Disability Verification Form
Office for Disability Services
Ohi
o State ATI/Wooster
Campus
128 Skou Hall
1328 Dover Road
Wooster, Ohio
44691
330-287-1258 Phone
cfaes-atiods@osu.edu
The Office for Disability Services (ODS) provides academic accommodations for students with diagnosed
disabilities. The purpose of this form is to assist medical providers in documenting a student’s relevant
disability information for determining accommodation eligibility. Note: This form serves as one option (not the
only option) for providing disability documentation to ODS. Other examples of documentation include: a
physician’s letter on letterhead, a diagnostic report, or an IEP/504 plan. To review our documentation
guidelines, visit our website (https://ati.osu.edu/currentstudents/studentservices/disability-services
).
Please take note of the following as you complete this form:
A. The person completing this form should be a healthcare professional who is either (1) qualified
to assess and diagnose the student’s condition, and/or (2) is a part of the student’s treatment
plan for a previously diagnosed condition. These professionals are generally trained, certified, or
licensed to diagnose and/or treat medical conditions. Examples include: psychiatrist, psychologist,
therapist, social worker, medical doctor, optometrist, speech-language pathologist.
B. Please complete all parts of this form as thoroughly as possible. Inadequate information, illegible
handwriting, or missing fields may delay the eligibility review process by necessitating follow up contact
for clarification. An editable PDF version of this form is available on our website
(https://ati.osu.edu/currentstudents/studentservices/disability-services
).
C. We invite you to attach to this form any other documents or information you think would be
relevant in determining the student’s academic accommodations.
D. The information you provide will be kept in the student’s file at Disability Services, where it will
be held securely and confidentially. This form may be released to the student at his/her request.
Once completed, please return this form back to the student so that they may upload it with their ODS
New Student Application (found on our website). If you have questions regarding this form, please call
ODS at 330-287-1258.
Thank y
ou for your assistance.
Updated 04-2020
STUDE
NT INFORMATION
(Please Print Legibly or Type)
First Name Middle Last
Date of Birth
Status (check
one)
☐current student ☐transfer student ☐prospective student
Local phone ( ) - - Cell phone ( ) - -
Address
If current Ohio State
student, email address: @buckeyemail.osu.edu
Other email
address
DIAGNOSTIC INFORMATION
(Please print legibly or type)
1. Date of Diagnosis:
2. Primary Diagnosis:
Other Diagnoses:
3. What is the severity of the disorder? ☐ Mild ☐ Moderate ☐ Severe
4. Please state the medication or treatment the student is currently prescribed:
Updated 04-2020
5. Please describe how the student’s disability symptoms or treatment plan impacts their academics:
6. Please state specific recommendations regarding academic accommodations for this student:
7. Please add any additional comments that you feel appropriate:
Updated 04-2020
HEALTHCARE PROVIDER INFORMATION
(Please sign and date below and completely fill in all other fields using PRINT or TYPE)
Provider Signature
Date
Provider Name (print)
Title
License or Certification #
Address
Phone Number
( ) - -
Fax Number
( ) - -
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signature
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Form 44691: Disability Verification Form The Office for (Ohio State University Agricultural Technical Institute)

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Completed 3 February 2021

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