Verification of Disability Form
Physical, Psychological, Sensory, and Other Medical Disorders
Sheridan Technical College (Main) Sheridan Technical College (West)
5400 Sheridan Street 20251 Stirling Road
Hollywood, FL 33021 Pembroke Pines, FL 33332
Tel: 754.321.5400/ Fax: 754.321.5518 Tel: 754-321-3900
Directions: Form must be completed by the appropriate qualified medical professional. Please attach any available
documentation to support diagnosis.
Student Name: ________________________________________________________ Student ID: _____________________________
Phone Number: _______________________________________________ Date of Birth:____________________________________
Diagnosis: ____________________________________________ Diagnosis Code (from DSM-V): _____________________________
IMPACT OF DISABILITY: What are the current functional limitations of the student of learning and/or performing effectively in an
educational setting?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Is this individual a danger to him/herself or others? _____ Yes _____ No
Please state any relevant behavioral observations: ___________________________________________________________________
MEDICATIONS: Please list any medication(s) the student is currently taking the side effect(s) the medication(s) may have on learning
such as: concentration, focusing, attention, etc.
Medication(s): Side Affect(s):
___________________________________________ ______________________________________________________
___________________________________________ ______________________________________________________
ACCOMMODATIONS RECCOMMENDED: Please state any recommendations for reasonable accommodations needed by the student.
Examples of specific recommendations may include: “50% extra time”, “small group testing (11-16)”, etc. Non-specific
recommendations such as “extra time” or “unlimited time” are not acceptable. Please remember, the provision of reasonable
accommodations must be based on objective evidence of a substantial limitation to learning and must be supported by test results,
clinical observations, etc. Accommodations are not given to ensure the student has plenty of time to finish test/assignment.
1._________________________________________ 3. _________________________________________
2. ________________________________________ 4. _________________________________________
Diagnostician’s Signature: _________________________________________________________________ Date: ______________
Print Name: _________________________________________________ Title:____________________________________________
Phone: ________________________________________________ Fax:_________________________________________________
For questions, please contact:
Ervean Shannon-Goff at 754-321-5447
ervean.shannon-goff@browardschools.com
Sheridan Technical College
5400 Sheridan Street, Hollywood, Fl 33021
Attention: Ervean Shannon-Goff
Physician’s office stamp here
