Lehigh Carbon Community College
Disability Support Services
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VERIFICATION OF DISABILITY FORM FOR MEDICAL PROVIDERS
Return to the attention of:
4525 Education Park Drive Abigail Wright
Schnecksville, PA 18078 Michelle Mitchell
Kristen Lenhart
Fax: 610-799-1068
Purpose: The student named below has indicated that s/he has a disability and will require reasonable
accommodations to participate in a program or activity at Lehigh Carbon Community College (LCCC). The
information you provide will be used to determine the nature and severity of the student’s condition and the
appropriateness of requested accommodations or services.
Please take the time to complete this form in its entirety. Contact Disability Support Services at 610-799-
1156 with any questions. All information provided will be kept confidential in accordance with the Family
Educational Rights and Privacy Act (FERPA).
The student’s signature below is permission for you to release information to DSS at LCCC. Thank you for
your assistance.
Please note: For hearing disabilities, please attach the most recent audiogram. For visual disabilities,
please attach acuity information. For neurological disabilities, any completed objective testing with results.
Student Name: (To be completed by student)
Student Signature: (To be completed by student)
Date of Birth: (To be completed by student)
The following information to be completed by provider:
1. Date of initial contact with student:
2. Date of last contact with student:
3. Does the student have a clinical history of the condition's symptoms? Yes No
a. Approximately at what age did the student start exhibiting symptoms?
b. At approximately what age was the student diagnosed with the condition?
4. Medical Diagnosis(es); DSM-IV/ID Codes:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V (GAF):
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5. What are the student’s current functional limitations?
Functional Limitation/Major Life Activities:
Reading
Writing
Math
Hearing
Seeing
Upper Body Motor Function
Lower Body Motor Function
Interpersonal Skills
Decision-Making
Stamina
Motivation/Initiative
Concentration
Memory
Following Instruction
Judgment
Psychosomatic (i.e. headache,
back pain, muscle cramps,
nausea, slowness and
speech/thought/movement)
Organization
Socialization/Teamwork
Attendance
Low Frustration Tolerance
Pain
Problems with Motor Coordination
Meeting Deadlines
Difficulties with Receptive Speech
Difficulties with Expressive Speech
Sensory
Performing Manual Tasks
Caring for Oneself
Working
Eating
Sleeping
Walking
Standing
Sitting
Reaching
Lifting
Bending
Speaking
Breathing
Learning
Reading
Concentrating
Fluency
Thinking
Communicating
Interacting with Others
Other Functional Limitation/Major Life Activity:
6. What is the severity of the student’s functional limitations noted above, both with and without the use of
mitigating measures (interventions), such as medication and treatment:
Without Mitigation (Intervention): With Mitigation (Intervention):
Mild Mild
Moderate Moderate
Substantial Substantial
Severe Severe
7. What exacerbates the condition this student has? (again, be as specific and detailed as possible)
Fatigue Weather
Stress Noise
Being Overwhelmed Crowds
Social Interactions
Other Items That Exacerbate Condition
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8. Please list any medications related to the condition(s) that the student is currently taking, including dosage
and frequency, if pertinent. Please include both the positive as well as any negative effects of the
medication:
Medication/Dosage/Frequency Side Effects
9. Please describe the evidence that the student's condition will interfere or reduce the quality of functioning in
the areas listed below. Write N/A if the period is not impacted by the condition.
School Functioning:
Social Functioning:
Work Functioning:
10. Was there specific condition related objective evaluations completed to obtain information about the
student's symptoms and functioning? Yes No
Please describe the specific evaluations completed.
If no, how did you reach your conclusion about the diagnosis and treatment?
11. Please list any recommended accommodations to help mitigate specific symptoms related to the student's
condition.
Recommended Accommodation Specific Symptom Mitigated
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Physician’s Contact Information
Name of Medical Professional:
Credentials:
License #:
State of Licensor:
Address:
Telephone:
E-mail Address:
Signature:
Date:
Signature of Provider:
PERM24B-c (AC)