Required for professional office
C:\Users\dwright\Desktop\Verification of Disability_082016.doc
(A photo copy is valid as the original)
Student’s Name:
Student ID#: Birth Date: Last four SS#: *
I hereby authorize the information requested below be released to DSPS at SDCCD.
_________________________________________________ _________________
Student’s Signature Date
Physician or Verifying Professional:
Phone #: Fax #:
Address: City: State: Zip:
SDCCD uses the information requested on this form for the purpose of determining a student's eligibility to receive authorized special services provided by DSPS. Personal information recorded on
this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with state or federal agencies; however, disclosure to these parties is
made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232(g)). Pursuant to Section 7 of the Federal Privacy
Act (Public Law 93-579; 5 U.S.C. § 552a, note), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections
67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000
VERIFYING PROFESSIONAL: List all disabilities and include information describing the student's disabling condition.
Current DSM/ICD and Severity (if applicable):
Describe substantial limitations to learning and other major life activities: i.e., problem solving, mobility, distractibility,
communication skills, medications or others that affect educational performance
___Permanent/ Chronic Date of Diagnosis:
___Temporary (date of re-evaluation or estimated duration of disability)
Signature of Licensed/Certified Professional Print Name
Professional Title (i.e., MD, Ph.D., etc,) License/Certification # Date
Please return by FAX or mail to the identified site below:
San Diego City College-DSPS
1313 Park Blvd.
San Diego, CA 92101-4721
619-388-3513 Voice 619-388-3313 TDD
FAX 619-388-3801
San Diego Mesa College - DSPS
7250 Mesa College Drive
San Diego, CA 92111-4998
619-388-2780 Voice 619-388-2974 TDD
FAX 619-388-2460
San Diego Miramar College - DSPS
10440 Black Mountain Road
San Diego, California 92126-2910
619-388-7312 Voice 619-388-7301 TDD
FAX 619-388-7917