Fillable Verification Form Physical Health Disorders Bucks County Community (Bucks County Community College)

Fill Online, Printable, Fillable, Blank Verification Form Physical Health Disorders Bucks County Community (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 Physical Health Disorders Bucks County Community (Bucks County Community College)

On average this form takes 22 minutes to complete

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

  • 1 signature
  • 11 check-boxes
  • 77 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
Physical Health Disorders
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Physical Health Disorders to
obtain current information from a licensed medical practitioner regarding a student’s physical health 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 medical reports or secondary school documentation. Any
documentation, including this Verification Form, must meet Bucks County Community College’s TAO guidelines for Physical Health
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 Physical Health
Disorders is as follows:
1. Evidence of current physical health impairment
2. Functional impairment affecting an important life skill, including academic functioning
3. Exclusion of alternative diagnoses
4. History relevant to current physical health impairment
5. 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?
2.
When was the student diagnosed with the condition?
Month
Year
Verification Form: Physical Health Disorders 2
The Accessibility Office Bucks County Community College
Physical Health Disorders Verification Form
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. Does the student’s physical health disorder cause mobility restrictions? If so, please explain in detail (e.g.,
distance student can ambulate without stopping or resting; necessity of elevator versus stairs; methods
used to negotiate mobility restrictions).
c. Is there clear evidence that the symptoms associated with the physical health 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:
Verification Form: Physical Health Disorders 3
The Accessibility Office Bucks County Community College
Physical Health Disorders Verification Form
d. 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):
e. 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 physical health disorder and associated
functioning (e.g., developmental, familial, medical, pharmacological, psychological, psychosocial).
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.):
Verification Form: Physical Health Disorders 4
The Accessibility Office Bucks County Community College
Physical Health Disorders Verification Form
Medication Dosage Frequency (e.g., Humira 40 mg 1 x biweekly):
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., 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., Humira 40 mg 1 x biweekly):
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: Physical Health Disorders 5
The Accessibility Office Bucks County Community College
Physical Health Disorders Verification Form
D. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current symptoms and then indicate what reasonable academic accommodations would
mitigate the symptom listed.
2. Sample: A student’s blood sugar may drop requiring the need for food or snacks.
Symptom: (Example)
Occasional drops in blood sugar
Recommended Reasonable Accommodation(s):
Food or drink permitted in classroom
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: Physical Health Disorders 6
The Accessibility Office Bucks County Community College
Physical Health 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 (i.e., licensed medical practitioner). 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 Physical Health Disorders Bucks County Community (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