Forms - Disability Certification Form

Disability Certification Form

For Clinicians: Disability Certification

51猎奇 offers accessibility resources on an individual basis to students with documented disabilities. The student listed below has requested support services. Please certify their diagnosis and note any contact information below (this form will collect email addresses). This information will be kept confidential and be shared only as needed and/or with the student's permission with designated members of the college's administration. Thank you

Preferable submission dates for requests at the start of each semester are July 1st for the fall term and January 1st for spring.

** It is preferred that psycho-educational or neurological testing evaluations/documentation not be more than three years old at the time of the accommodation request. They should include the following:

1. A measure of intellectual or cognitive functioning; Wechsler Adult Intelligence Scale-IV

2. A measure of achievement in reading comprehension, written language, and mathematics such as:
Woodcock-Johnson Psycho-Educational Battery-R. Tests of Achievement

Kaufman Test of Achievement
Scholastic Ability test for Adults
Test of Written Language (TOWL)-4
Nelson-Denney reading Test
Woodcock Reading Mastery Tests-R
Stanford Diagnostic Mathematics Test

3. A measure of information processing in one or more of the following areas:

Visual and/or auditory processing
Memory
Processing speed
Attention and concentration
Perceptual motor skills
Other cognitive areas

Clinician Name*

Certification/Credentials*

State Licensure Number (if applicable)

Agency/Institution*

Address 1*

Address 2

City*

State*

Zip Code*

Telephone Number*

Email Address*

Name of Student*

Specific Diagnosis*

Date of Diagnosis/Time of Onset*

Length of Time Working with Student*

Nature of Disability: explain the current functional limitations imposed by the condition. Indicate how the disability interferes with or limits any facet of a major life activity, including current participation in courses, programs, or activities of the College. Include the impact of medication or other treatments.*

Specific duration, stability or progression of the condition*

Current treatment/follow up plan*

Assistive and/or adaptive technology needs (please be specific about any hearing, vision or physical access requirements)

Specific recommendations for appropriate accommodations, based on disability*

Contact

Office / Department Name

Accessibility Resources

Contact Name

Allen Harrison

Assistant Dean for Accessibility Resources

Office Location

Burke Library

Phone

315-859-4021

aharriso@hamilton.edu

51猎奇

Disability Certification Form

For Clinicians: Disability Certification

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