Fillable Towson DSS Physical/ Medical Disability Form (Towson University)

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Towson DSS Physical/ Medical Disability Form (Towson University)

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The Towson DSS Physical/ Medical Disability Form (Towson University) form is 5 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 220 other fields

Country of origin: US
File type: PDF

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1
Rev. 06/15
Disability Support Services
8000 York Road
Towson, MD 21252
t.410-704-2638
f.410‐704‐4247
www.towson.edu/dss
DISABILITY VERIFICATION FOR STUDENTS WITH PHYSICAL OR MEDICAL DISABILTY
The student named on the following page has asked to register with Disability Support Services (DSS) at
Towson University.
Under the Americans with Disabilities Act as amended (ADAAA) and Section 504 of the Rehabilitation Act
of 1973, individuals with disabilities are protected from discrimination and may be entitled to reasonable
accommodations. Federal law defines a disability as a physical or mental impairment that substantially
limits a major life activity (e.g., learning, reading, concentrating, and thinking). As part of the interactive
process to determine what, if any, reasonable accommodations may be provided, DSS requires current
and comprehensive documentation of the student’s impairment. A diagnosis alone does not
automatically qualify a student for accommodations. Disability documentation is reviewed by DSS staff
on a case‐by‐case basis and, in addition, DSS staff will meet directly with the student to determine
eligibility for services.
Qualified Professional: The diagnosis must be provided by a licensed health care provider such as a
medical doctor, doctor of osteopathic medicine, registered nurse, nurse practitioner, or physician’s
assistant. The diagnostician must be an impartial individual who is not a close friend of the family or a
family member of the student.
After completing this form, please fax or mail it to DSS at the address above. The information you
provide will be maintained in a secure and confidential file within the DSS office. Please contact the DSS
if you would like further information. Thank you for your assistance.
*Please note: This form must be completed in its entirety to be considered as acceptable
documentation.
2
Rev. 06/15
Disability Verification for Students with Physical or Medical Disabilities
To be completed by the student’s health care provider
Student’s name______________________________________________________DOB______________________
Today’s date_________________________ Date of diagnosis:___________________________________________
This student has been under a physician’s care for this issue since:________________________________________
Date student was last seen________________________How often do you see this student? __________________
Diagnosis (es): _________________________________________________________________________________
_____________________________________________________________________________________________
How long is this condition likely to persist? __________________________________________________________
1. How did you arrive at your diagnosis? Check all that apply and include relevant findings to a checked area.
□
Interview with student ____________________________________________________________
_______________________________________________________________________________
□
Interview with significant others_____________________________________________________
_______________________________________________________________________________
□
Behavioral observations___________________________________________________________
_______________________________________________________________________________
□
Developmental history____________________________________________________________
_______________________________________________________________________________
□
Medical history__________________________________________________________________
_______________________________________________________________________________
□
Medical tests__________________________________________________________________
_______________________________________________________________________________
3
Rev. 06/15
Disability Verification for Students with Physical or Medical Disabilities
2. Please list any coexisting conditions that should be considered when determining accommodations.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. Identify the level of impact the student’s physical or medical disability has on major life activities and learning.
1= Unable to Determine 2= No Impact 3= Mild Impact 4= Moderate Impact 5= Substantial Impact
1
2
3
4
5
Major Life Activities
2
3
4
5
Learning
Maintaining
appropriate hygiene
Memory
Talking
Concentrating
Hearing
Listening
Seeing
Organizing/Prioritizing/Planning
Breathing
Managing external distractions
Sitting
Managing internal distractions
Walking
Timely submission of
assignments
Standing
Attending classes and
appointments as scheduled
Eating
Managing deadlines
Sleeping
Collaborating with classmates
on group projects
Performing Manual
tasks
Managing stress
Lifting/Carrying
Reading
Interacting with others
Writing
Spelling
Test taking
Processing Speed
4
Rev. 06/15
Disability Verification for Students with Physical or Medical Disabilities
4. Describe current symptoms that impact the student’s ability to perform in a college setting.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. What is the student’s prognosis?_________________________________________________________________
6. How long do you anticipate that the student’s performance in a college setting will be impacted by the
disability?
□ 6 months □ 1 year □ 1-2 years □ on-going □ unknown
7. Have there been any changes in the student’s condition in the past 12 months? If yes, please explain.
□ No
□ Yes _________________________________________________________________________________
______________________________________________________________________________________
8. Do you anticipate any changes in the student’s condition or medication in the next 12 months? If yes, please
explain.
□ No
□ Yes _________________________________________________________________________________
______________________________________________________________________________________
9. List medications the student is currently taking for this condition.
Medication
Side Effects
Academic Impact
Persistence of Symptoms
5
Rev. 06/15
Disability Verification for Students with Physical or Medical Disabilities
10. If the nature of the student’s condition is episodic, what is the typical frequency and duration of the episodes?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
11. If the condition is a seizure disorder, approximately how many seizures has the student had in the past 6
months?
_____________________________________________________________________________________________
12. Indicate your recommendations and justifications regarding reasonable accommodations in the college
environment.
Recommended Accommodation
Justification
Please note: A reasonable accommodation is a modification or adjustment to a course or program that
eliminates or minimizes disability‐related barriers and enables a qualified student with a disability to
participate.
At the college level, the purpose of an accommodation is to correct or circumvent a
functional impairment rather
than to ensure a student’s success. In reviewing the accommodation requested by the student or recommended
by an evaluator, the DSS
office may find that the accommodation is not appropriate given the requirements of a
course or
program. DSS may propose an alternative accommodation that would be appropriate for the student,
but which neither the student nor evaluator has requested.
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Address:
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Towson DSS Physical Medical Disability Form (Towson University)

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Completed 26 July 2020

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