Verification Mobility Disability

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Verification Mobility Disability Powered By Docstoc
					                                                             1179 University Drive
                                                             Newark, Ohio 43055-1797
                                                             TEL (740) 366-9441
                                                             FAX (740) 364-9646


                       Office for Disability Services


                    VERIFICATION OF A MOBILITY DISABILITY

The Office for Disability Services provides services to students with mobility disabilities.
In order to determine eligibility for services and appropriate accommodations, this office
requires current and comprehensive documentation of the mobility impairment from the
diagnosing medical professional or other appropriate professional.

Please answer the following questions pertaining to:

Date: November 3, 2012

Last four digits of Social Security #:

1.     What is the diagnosis, date of diagnosis, and last contact with the student?




2.     Please describe the progression of this condition if applicable.




3.     Describe the symptoms that meet the criteria for the diagnosis. Also, describe
       how this mobility disability may affect this student both academically and/or
       physically (functional limitations).
Office for Disability Services – VERIFICATION OF A MOBILITY DISABILITY                 2



4.    List current medication(s), dosage, frequency, and adverse side effects.




5.    What recommendations do you have regarding accommodations, i.e. extra time
      for exams, note taker, disability parking, adaptive transportation. Please
      describe your rationale for the accommodations you have recommended.




6.    Are there other associated disabilities? If so, what are they? Please describe
      these conditions and any functional limitations.
Office for Disability Services – VERIFICATION OF A MOBILITY DISABILITY       3




Signature: _____________________________________________________________

Print Name and Title: ____________________________________________________

Address: ______________________________________________________________

______________________________________________________________________

Telephone: ____________________________________________________________

Send the completed document to:   Connie S. Zang, MA
                                  Office for Disability Services
                                  1179 University Drive
                                  Newark, Ohio 43055-1797

                                  Fax (740) 364-9646

				
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posted:11/4/2012
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