Please return this form to the SAS office as soon as possible.
A PHOTO COPY IS AS VALID AS THE ORIGINAL
Student Accessibility Services
2100 Moorpark Avenue, San Jose, CA 95128-2799
Phone: 408-288-3746
Fax: 408-971-8201
Email: sjcc.sas@sjcc.edu
VERIFICATION OF DISABILITY
THIS SECTION BELOW MUST BE COMPLETED BY THE STUDENT
Date:
Student ID#:
First Name:
Last Name:
Date of Birth:
/ /
Phone number:
Secondary Phone number:
THIS SECTION BELOW MUST BE COMPLETED BY THE LICENSED OR CERTIFIED PROFESSIONAL
The student named above is requesting services at San Jose City College. In order to provide appropriate services to this student,
we are required to obtain the following verification of disability/diagnosis
Name of Licensed/Certified Professional:
Title/License #:
Address:
City:
State:
Telephone Number:
Fax Number:
To assist us in determining reasonable educational accommodations, please provide the following information IN FULL.
Diagnosis:
DSM IV Code and Severity (if applicable):
Condition is:
Stable Prone to exacerbation
Duration of Condition:
Permanent/Chronic Temporary until date: __________/__________/__________
Prescribed Medications and Dosage:
Functional limitations: Indicate how the disability, condition and/or side effects of the medication affect the student.
Please list other limitations/information helpful in determining accommodations in an educational setting:
I understand that the information provided On this form will become part of the student record, and may be released to the student
upon their written request.
Signature:
Verifying Licensed/Certified Professional
Date
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signature
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