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Office of Student Accessibility: Disability Verification Form
Student Name (required):
Student Sacred Heart University ID (required):
In order to be eligible for disability services the individual requesting (student) must have a documented disability
as defined by Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 and
Amendment of 2008 defined as a physical or mental impairment that substantially limits one or more major life
activities.
Please note:
Any information provided to the Office of Student Accessibility (OSA) becomes part of the student’s
“educational record”. Under privacy protections and access provisions of FERPA, the student, when
requested, has the right to inspect their own educational records.
A learning disability diagnosis must be accompanied by a current and appropriate psychoeducational
evaluation, including the diagnostic test scores.
Additional documentation may be required by the OSA
For the Treating Clinician and/or Diagnostician:
You have been asked by your patient/client to complete this verification form providing documentation of a
disability based on Section 504 of the Rehabilitation Act and The Americans with Disabilities Act of 1990 and
Amendment of 2008. Please complete this form in its entirety and attach any additional information. Verification
forms returned partially complete could result in a delay or denial of accommodations. In order to accurately
complete this form you must:
Have knowledge of the student’s current level of functioning and any potential access barriers this may
present at the university level
Complete the following verification form with current knowledge of the student
Return this form to:
Beth Skudzienski, Assistant Director, Office of Student Accessibility
5151 Park Ave, Fairfield CT, 06825 Fax: 203-396-8049 email: accessibility@sacredheart.edu
If you have any questions about this process or require assistance, contact Beth Skudzienski.
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Full Student Name (first, middle, last) (required):
Student date of birth (required)
Date of last office visit (required):
Full Student Address (required):
Formal Student Diagnosis (date of diagnosis, DSM-V/ICD-10 codes, including Axis I, II, III, IV
and V. (required) :
Expected Duration of Diagnosis (permanent, temporary, chronic, episodic and reoccurring)
(required):
Methodology used to obtain diagnosis & symptoms that determine the diagnosis (required):
Impact of symptoms associated with academics and/or residential life (residential life specific to housing
requests only) (required):
Severity of condition (required): Mild Moderate Substantial
Current medications, dosage frequencies and potential adverse side effects of these (required):
Current therapies and other treatments, frequencies of these and any anticipated hospital stays (required):
For allergies of any kind (including seasonal allergies and asthma), please list prescription medications taken
and frequency these medications are taken (required):
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Substantial Impact to Major Life Activities:
Definition: The patient/client’s activities are significantly restricted when compared to the average individual in the
general population when considering the conditions, manner or duration under which the activities can be
performed.
Directions: Please check all functional limitations, including information on how each will impact your patient/client
within the academic environment (required):
Functional Limitation-please check all that apply (this section is required):
1. Caring for Oneself
a. Mild
b. Moderate
c. Substantial
d. Comments:
2. Performing Manual Tasks
a. Mild
b. Moderate
c. Substantial
d. Comments:
3. Seeing
a. Mild
b. Moderate
c. Substantial
d. Comments:
4. Breathing
a. Mild
b. Moderate
c. Substantial
d. Comments:
5. Sleeping
a. Mild
b. Moderate
c. Substantial
d. Comments:
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6. Eating
a. Mild
b. Moderate
c. Substantial
d. Comments:
7. Standing
a. Mild
b. Moderate
c. Substantial
d. Comments:
8. Lifting
a. Mild
b. Moderate
c. Substantial
d. Comments:
9. Bending
a. Mild
b. Moderate
c. Substantial
d. Comments:
10. Walking
a. Mild
b. Moderate
c. Substantial
d. Comments:
11. Speaking
a. Mild
b. Moderate
c. Substantial
d. Comments:
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12. Learning
a. Mild
b. Moderate
c. Substantial
d. Comments:
13. Reading
a. Mild
b. Moderate
c. Substantial
d. Comments:
14. Concentrating
a. Mild
b. Moderate
c. Substantial
d. Comments:
15. Thinking
a. Mild
b. Moderate
c. Substantial
d. Comments:
16. Communicating
a. Mild
b. Moderate
c. Substantial
d. Comments:
17. Memory
a. Mild
b. Moderate
c. Substantial
d. Comments:
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18. Working
a. Mild
b. Moderate
c. Substantial
d. Comments:
19. Operation of a Major Bodily Function
a. Mild
b. Moderate
c. Substantial
d. Comments:
20. Other
a. Mild
b. Moderate
c. Substantial
d. Comments:
21. Other
a. Mild
b. Moderate
c. Substantial
d. Comments:
Suggested Reasonable Accommodations:
Each suggestion and rationale must be supported by a diagnosis previously documented on this form.
Please note-suggested accommodations will be considered, but are not automatically included as part of a
student’s reasonable accommodations at Sacred Heart University.
1. Suggested Accommodation
a. Rationale
b. Functional Limitation this may accommodate
2. Suggested Accommodation
a. Rationale
b. Functional Limitation this may accommodate
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3. Suggested Accommodation
a. Rationale
b. Functional Limitation this may accommodate
Relevant background information including developmental, medical, academic, psychosocial, family, etc…
(required):
Additional Information/Comments (required):
Practitioner Name &Title: Practitioner Signature:
Specialty/Qualifications for Determining Diagnosis (required):
State License and/or Certification Number (required):
Address: Phone: Fax:
Date form signed (required):
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