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
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
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 V (GAF):