Fillable Verification Form Neurological Disorders Bucks County Community Colleges (Bucks County Community College)

Fill Online, Printable, Fillable, Blank Verification Form Neurological Disorders Bucks County Community Colleges (Bucks County Community College) Form

Use Fill to complete blank online BUCKS COUNTY COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Verification Form Neurological Disorders Bucks County Community Colleges (Bucks County Community College)

On average this form takes 21 minutes to complete

The Verification Form Neurological Disorders Bucks County Community Colleges (Bucks County Community College) form is 6 pages long and contains:

  • 1 signature
  • 13 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bucks County Community College

BROWSE BUCKS COUNTY COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Newtown Campus • Student Services Center • Rollins Building • 275 Swamp Road • Newtown • PA • 18940
(215) 968-8182 • (215) 968-8033 fax • accessibility@bucks.edu • http://www.bucks.edu/student/accessibility/
Adapted by permission from The Pennsylvania State University
Verification Form
Neurological Disorders
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Neurological Disorders to
obtain current information from a qualified practitioner (e.g., physician, neurologist, and neuropsychologist) regarding a student’s
neurological disorder, associated symptoms, related medications, and their impact on the student and his or her need for
accommodations. This Verification Form may supplement information that is provided in other reports, including neurological
reports, neuropsychological evaluations, or secondary school documentation. Any documentation, including this Verification Form,
must meet Bucks County Community College’s TAO guidelines for Neurological Disorders. The person completing this form may not
be a relative of the student or hold power of attorney over the student.
A summary of the guideline criteria for documenting hearing impairments can be found at the following web site:
http://www.bucks.edu/student/accessibility/student-info/. A summary of the guideline criteria for documenting Neurological
Disorders is as follows:
1. Evidence of current neurological impairment
2. Functional impairment affecting an important life skill, including academic functioning
3. Symptoms and functional impairment attributed to neurological disorder determined through the administration of a
neurological diagnostic test and/or a neuropsychological evaluation
4. Exclusion of alternative diagnoses
5. History relevant to current neurological impairment
6. Summary and recommendations
Section I: Student Information (Please type information or print legibly)
Student Name:
Last
First
Middle
Student ID:
Cell Phone:
Bucks Email:
Permanent Street
Address:
City:
State:
Zip:
Local Street
Address:
City:
State:
Zip:
Section II: Provider Section (Please type information or print legibly)
A. Contact with the Student:
Date of initial contact with the student:
Date of last contact with the student:
Frequency of appointments with student
(e.g., once a week, once a month):
B. Diagnosis Information:
1. What is the student’s diagnosis?
Verification Form: Neurological Disorders 2
The Accessibility Office Bucks County Community College
Neurological Disorders Verification Form
2.
When was the student diagnosed with the condition?
Month
Year
3.
What is the severity of the impairment?
Mild
Moderate
Severe
a. Explain the severity checked above:
4. What is the expected duration of the impairment?
Short-term (<6 months):
Long-term (>6 months-1 year):
Episodic:
Chronic (>1 year with frequent recurrence):
c. Explain the duration checked above:
5. Current Symptoms:
a. Please provide information regarding the student’s current presenting symptoms:
b. Is there clear evidence that the symptoms associated with the neurological disorder are interfering with or
reducing the quality of at least one of the following, including academic functioning?
Environmental Functioning:
School functioning:
Social functioning:
Work functioning:
c.
Did you use a neurological diagnostic test and/or neuropsychological evaluation to
Yes
NO
obtain information about the student’s symptoms and functioning in various
settings?
Verification Form: Neurological Disorders 3
The Accessibility Office Bucks County Community College
Neurological Disorders Verification Form
d. If yes, on what date(s) was the neurological diagnostic test and/or neuropsychological evaluation
completed? Please include a copy of the test/evaluation with the submission of this Verification Form.
e. If no, how did you reach your conclusion about the neurological disorder diagnosis, symptoms, and
treatment?
f. DSM Codes
Please include all pertinent diagnoses or rule-out diagnoses using DSM codes.
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V (GAF):
g. ICD-10-CM Diagnosis Codes:
Please include all pertinent diagnoses or rule-out diagnoses using ICD-10-CM codes.
C. Student’s History:
1. Please include any historical information relevant to the student’s neurological disorder and associated
functioning (e.g., developmental, familial, medical, pharmacological, psychological, and psychosocial).
Verification Form: Neurological Disorders 4
The Accessibility Office Bucks County Community College
Neurological Disorders Verification Form
D. Medications:
1.
Is the student currently taking medication(s) for any symptoms related to the
diagnosis?
Yes
NO
2.
If yes, please provide information below for each medication the student is currently prescribed:
Medication Dosage Frequency (e.g., Tramadol 100 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication Dosage Frequency (e.g., Adderall 5 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication Dosage Frequency (e.g., Keppra 1000 mg 2 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication Dosage Frequency (e.g., Keppra 1000 mg 2 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Verification Form: Neurological Disorders 5
The Accessibility Office Bucks County Community College
Neurological Disorders Verification Form
D. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current hearing loss symptoms and then indicate what reasonable academic
accommodations would mitigate the symptom listed.
2. Sample: student may have a seizure and experience prolonged fatigue afterward causing difficulty taking a
scheduled exam.
Symptom: (Example)
Seizures followed by fatigue
Recommended Reasonable Accommodation(s):
Opportunity to reschedule exams/quizzes
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Verification Form: Neurological Disorders 6
The Accessibility Office Bucks County Community College
Neurological Disorders Verification Form
Section III: Provider’s Certifying Professional Information:
(Please type information or print legibly)
Professionals conducting the assessment, rendering a diagnosis, and providing recommendations for reasonable
accommodations must be qualified to do so (e.g., licensed physician, neurologist, and neuropsychologist). The provider
signing this form must be the same person answering the above questions.
Provider’s Name:
Last
First
Middle
Credentials:
License Number:
Phone Number:
Practice Street
Address:
City:
State:
Zip:
May this completed Verification Form be released to the student?
Yes
NO
Provider Signature:
Date:
Section IV: Submitting this Form
This form should be returned to the Accessibility Office (TAO) at Bucks County Community College where the
student is enrolled. All forms need to be submitted at the Newtown campus. Please see the following
methods of submission of this form:
Email: accessibility@bucks.edu
Fax: (215) 968-8033
USPS: Bucks County Community College
Attention: The Accessibility Office
275 Swamp Road
Newtown, Pennsylvania 18940
Physical Newtown Campus
Drop Off: Rollins Center • Student Services Office • Room 001
Information regarding the Accessibility Office (TAO) at Bucks County Community College can be found at
http://www.bucks.edu/student/accessibility/. Please visit our website for the latest information and updates
as they are made available. If you have any questions, please feel free to call us (215) 968-8182.
Bucks County Community College does not discriminate in its educational programs, activities or employment practices based on race, color, national origin, sex,
sexual orientation, disability, age, religion, ancestry, veteran status, union membership, or any other legally protected category.
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Verification Form Neurological Disorders Bucks County Community Colleges (Bucks County Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document