Fillable Learning-Disability-Documentation-Form Learning Disability Documentation Form[2]

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Learning-Disability-Documentation-Form Learning Disability Documentation Form[2]

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The Learning-Disability-Documentation-Form Learning Disability Documentation Form[2] form is 4 pages long and contains:

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  • 16 check-boxes
  • 28 other fields

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PO Box 1129 • Eunice, LA 70535
Science Building Room 145
337-550-1204 • Fax 337-550-1268
www.lsue.edu/studentaffairs • ods@lsue.edu
JANUARY 2019
LEARNING DISABILITY
DOCUMENTATION CHECKLIST
Documentation for each of the following MUST be included and attached with your request for
accommodations for your request to be considered:
¨ Diagnostic Interview (including history)
¨ Aptitude – (Suggested Tests Include):
o Wechsler Adult Intelligence Scale-III
o Woodcock-Johnson Psychoeducational Battery Revised: Test of Cognitive Ability
o Kaufman Adolescent and Adult Intelligence
o Stanford-Binet Intelligence Scale (4th Ed.)
¨ Achievement – (Suggested Tests Include):
o Scholastic Abilities Test for Adults
o Stanford Test of Academic Skills
o Woodcock-Johnson Psychoeducational Battery-Revised: Test of Achievement
o Wechsler Individual Achievement Test
o Information Processing (if applicable)
NOTE: Screening instruments such as the WRAT or abbreviated testing instruments do not provide enough
detailed information and may not be sufficient to determine eligibility for accommodations.
JANUARY 2019
PO Box 1129 • Eunice, LA 70535
Science Building Room 145
337-550-1204 • Fax 337-550-1268
www.lsue.edu/studentaffairs • ods@lsue.edu
LEARNING DISABILITY
DOCUMENTATION REQUEST FORM
(TO BE COMPLETED BY QUALIFIED PROFESSIONAL)
When completing this form, please PRINT or TYPE and COMPLETE ALL FIELDS.
Incomplete forms will not be accepted.
**** If you have a formal evaluation, please attach the documentation. ****
This student is requesting an auxiliary aid or service, academic adjustment, and/or other accommodations from
Disability Services. In order to consider this request, as well as to ensure the provision of reasonable and
appropriate auxiliary aids and services, University Policy requires that a Qualified Professional provide current and
comprehensive documentation of the disability. A qualified professional includes a licensed psychiatrist,
psychologist, medical doctor, or other qualified medical or mental health professional who is not a family member
of the student. IN ORDER TO BE CONSIDERED CURRENT, THE QUALIFIED PROFESSIONAL’S EVALUATION MUST BE
WITHIN THREE (3) YEARS PRIOR TO THE DATE OF THE MOST RECENT REQUEST FOR DISABILITY
ACCOMMODATIONS.
Student’s Name: _____________________________________ LSUE ID Number: ____________________
Date of Birth: ________________________________________________________________________________
Mailing Address __________________________________ City & Zip Code __________________
Phone Number: ______________________________________
1. Diagnosis (as diagnosed by the DSM-5) ___________________________________________________________
2. Date of Diagnosis: ______________________ Date of Last Contact with Student: _______________________
3. For the purpose of determining academic adjustments, describe the severity and longevity of the substantial
limitations due to a learning disability.
JANUARY 2019
LEARNING DISABILITY DOCUMENTATION REQUEST FORM | Page 2
4. Describe the student’s functional limitations in an educational setting (i.e., current and/or anticipated
problems associated with the condition):
5. List current medication, along with any current side effects that may impact academic performance:
6. Please indicate the RECOMMENDATIONS you have regarding reasonable and appropriate auxiliary aids or
services, academic adjustments or other accommodations to ensure equity for the student’s academic success
based on the functional limitations indicated above.
Please check all that apply: ___ Extended Time (1.5X) ___ Distraction Reduced Environment
___ Alternative Test Format ___ Consideration for Absences ___ No Scantron
___ Books on Tape ___ Enlarged Text (font size ___) ___ Reader ___ Scribe
___ Other _____________________________________________________________________________
Qualified Professional’s Signature: ___________________________________________________
Printed Name & Title: ______________________________________________________________
Daytime Telephone Number: ________________________________________________________
Address ____________________________________________ City & Zip ____________________
Date: ______________________________________________
Submit this form and all necessary documentation via scan/email, fax, mail, or in person to:
Office of Disability Services
Louisiana State University Eunice
PO BOX 1129 • Eunice, LA 70535
Science Building Room 145
Phone: 337-550-1204 • Fax: 337-550-1268
Email: ods@lsue.edu
JANUARY 2019
PO Box 1129 • Eunice, LA 70535
Science Building Room 145
337-550-1204 • Fax 337-550-1268
www.lsue.edu/studentaffairs • ods@lsue.edu
REQUEST FOR ACCOMMODATIONS
(TO BE COMPLETED BY STUDENT)
Student’s Name: _____________________ LSUE ID Number: _______________________
Date of Birth: ______________________ Phone Number: _____________________________
Mailing Address _______________________________________________________________
City & Zip Code __________________________________________
I am requesting accommodations because I have been diagnosed with one or more of the following
disabilities which functionally impairs my ability to perform in an academic environment (Check all
that apply):
___ Attention Deficit/Hyperactivity Disorder ___ Learning Disability
___ Psychological Disability ___ Deaf & Hard of Hearing
___ Physical or Systemic (Medical) Disability (specify): _________________________________________
In the space below, list and explain the reason for each of the accommodations you are requesting.
What accommodations, if any, have you received in the past? (i.e. during high school etc.) Please be as
specific as possible.
Signature of Student: ______________________________________ Date: ______________________________
NOTE: The Office of Disability Services does not provide copies of any documentation. ODS strongly
recommends maintaining copies of any submitted documentation for your personal records.
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Learning-Disability-Documentation-Form Learning Disability Documentation Form2

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Completed 2 July 2020

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