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BROWSE BUCKS COUNTY COMMUNITY COLLEGE FORMS

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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
Vision Impairments
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Vision Impairments to obtain
current information from a qualified practitioner (e.g., optometrist, ophthalmologist) regarding a student’s vision impairment and its
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 Vision Impairments conditions. 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 Vision Impairments
is as follows:
1. Evidence of current vision impairment
2. Functional impairment affecting an important life skill, including academic functioning
3. History of use of visual aids or assistive technology related to vision impairment
4. 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: Vision Impairments 2
The Accessibility Office Bucks County Community College
Vision Impairments 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. What is the student’s current best-corrected visual acuity and visual field in each eye (please explain in
detail)?
Visual Acuity (e.g., 20/XX)
Visual Field (e.g., XX degrees)
Distance
Near
Central
Peripheral
b. Is the vision loss expected to remain stable or is it expected to decline? If it is expected to decline, please
describe the expected progression of the vision loss.
c. Describe the proficiency of orientation and mobility of the student for independent travel (e.g., proficient in
cane usage; uses a guide animal; has usable vision; uses GPS technology or other technologies; needs
additional O & M training).
Verification Form: Vision Impairments 3
The Accessibility Office Bucks County Community College
Vision Impairments Verification Form
d. Is there clear evidence that the symptoms associated with the vision impairment 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:
Language functioning:
C. Student’s History:
1. Please include any historical information relevant to the student’s vision impairment and associated
functioning (e.g., developmental, familial, medical, pharmacological, psychological, and psychosocial).
2. Assistive Technology (AT):
a. Are glasses, contacts, or other visual aids prescribed to assist the student’s visual acuity? If so, what is the
visual acuity with the glasses, contacts, or visual aids?
b. What does the student use to access print (e.g., size of enlarged print; Braille; text reader; screen reader)?
c. If the student currently uses assistive or adaptive technologies to facilitate visual performance, please list
specifics related to the brand, model number, and proficiency of and setting for use (e.g., educational,
home, work).
Verification Form: Vision Impairments 4
The Accessibility Office Bucks County Community College
Vision Impairments Verification Form
3. ICD-10-CM Diagnosis Codes: Please include all pertinent diagnoses or rule-out diagnoses using ICD-10-CM
codes.
Please include all pertinent diagnoses or rule-out diagnoses using ICD-10-CM codes.
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., 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., 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., Adderall 5 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
D. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current symptoms associated with the vision impairment and then indicate what
reasonable academic accommodations would mitigate the symptom listed.
2. Sample: Due to vision impairment, the student cannot read written information.
Verification Form: Vision Impairments 5
The Accessibility Office Bucks County Community College
Vision Impairments Verification Form
Symptom: (Example)
Visual acuity extremely low
Recommended Reasonable Accommodation(s):
Reader for tests or use of screen reading program (i.e., JAWS)
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):
Symptom:
Recommended Reasonable Accommodation(s):
Verification Form: Vision Impairments 6
The Accessibility Office Bucks County Community College
Vision Impairments 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., optometrist, ophthalmologist). 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.
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Completed 3 October 2020

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