VERIFICATION OF ATTENTION DEFICIT HYPERACTIVITY DISORDER

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					                                                           Verification of Attention Deficit Hyperactivity Disorder   1




Office for Disability Services, Penn State Harrisburg
109 Swatara Building • 777 W Harrisburg Pike • Middletown, PA 17057-4898
Phone: 717-948-6025 • Fax: 717-948-6108



 VERIFICATION FORM for ATTENTION DEFICIT/ HYPERACTIVITY
                   DISORDER (AD/HD)
I. Student Section:
A student’s documentation regarding the Attention Deficit/Hyperactivity Disorder (AD/HD) must
demonstrate a disability covered under Section 504 of the Rehabilitation Act of 1973 and the Americans
with Disabilities Act (ADA) of 1990. These laws define a disability as a physical or mental impairment
that substantially limits one or more major life activities.

To determine eligibility for academic adjustments, auxiliary aids, and/or services, Penn State requires
current and comprehensive documentation of the student’s disorder. It is the responsibility of the student to
obtain documentation and present a copy to the Office for Disability Services (ODS) at the University Park
location or to the Disability Contact Liaison (DCL) at other Penn State locations. The documentation will be
reviewed to determine eligibility for academic adjustments, auxiliary aids, and/or services.

Specific reporting format is left to the professional, but the required components must be clearly presented
and easily discernable. Regardless of the format used, assessment reports must include all information
required by the Penn State Guidelines for documenting the student’s disorder. The guidelines for
documenting AD/HD can be found at the following web site:
http://www.equity.psu.edu/ods/guidelines/adhdguidelines.asp Not providing all information required may
prevent the student from receiving academic adjustments, auxiliary aids, and/or services from Penn State.

A summary of the guideline categories for documenting AD/HD is as follows:

   1. Presenting concerns at the time of evaluation;
   2. History (developmental, family, medical, psychosocial, psychological, pharmacological, educational,
      employment);
   3. Psycho-educational testing;
   4. Psychosocial functioning;
   5. A DSM IV Diagnosis with a corresponding diagnostic code;
   6. Functional limitations; and
   7. Summary and recommendations.

In addition to the documentation guidelines for AD/HD, the student must have their provider fill out the
Verification Form for AD/HD. The Verification Form for AD/HD is not to be utilized in place of the
documentation requirements; rather, it is supplemental to a full neurological evaluation and report
from the evaluator.

The student is required to complete the information in full on the next page of this document.
                                                       Verification of Attention Deficit Hyperactivity Disorder   2
Student Completes This Section (Please Print or Type):
Penn State University requires the student sign the release of information below giving the Office for
Disability Services (ODS) or the Disability Contact Liaison (DCL) permission to speak with the provider to
answer questions related to the documentation. The student must complete page 2, and the student’s
provider must complete pages 3-10. Both the student section and the provider section of the completed
verification form (pages 1-10, items 1-13) must be returned. If the student is attending the University Park
location, the form should be returned to the ODS. If the student is attending another Penn State location,
the form should be returned to the DCL at that location.

Student Name (First, Middle, Last):
PSU ID #:                         If PSU ID is not known, fill in Social Security#:


PSU Location attending:

Status:     Current Student              Transfer Student                        Prospective Student

Birth Date:                                                       Gender: Male                       Female


Home Address: Street


City                                  State                                                 Zip


Home Phone #:                                     Home E-Mail Address:

Local Address: Street

City                                  State                                                 Zip

Local Phone #:                                    Local E-Mail Address:


AUTHORIZATION TO RECEIVE INFORMATION: I authorize the Office for Disability Services to receive
information from the provider below. I also authorize my provider to discuss my condition(s) with the Office
for Disability Services.

Name of Provider:

Provider’s Address: Street

City                                  State                                                 Zip


Student’s Signature: _________________________________                    Date:_______________________

This verification form is not to be utilized in place of the documentation requirements above;
rather, it is supplemental to a full report from the provider. Remember to sign and date the form
once it is printed out.
                                                           Verification of Attention Deficit Hyperactivity Disorder   3




Office for Disability Services, Penn State Harrisburg
109 Swatara Building • 777 W Harrisburg Pike • Middletown, PA 17057-4898
Phone: 717-948-6025 • Fax: 717-948-6108

  VERIFICATION FORM for ATTENTION DEFICIT/HYPERACTIVITY
                    DISORDER (AD/HD)
II. Provider Section:
Penn State University provides academic adjustments, auxiliary aids and/or services to students with
disabilities. In order for a student to be eligible for academic adjustments, auxiliary aids, and/or services,
the student’s documentation regarding the disorder must demonstrate a disability covered under Section
504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990. These laws
define a disability as a physical or mental impairment that substantially limits one or more major
life activities. To determine eligibility for academic adjustments, auxiliary aids, and/or services, Penn
State requires current and comprehensive documentation of the student’s disorder. It is the responsibility of
the student to obtain documentation and present a copy to the Office for Disability Services (ODS) at the
University Park location or to the Disability Contact Liaison (DCL) at other Penn State locations. The
documentation will be reviewed to determine eligibility for academic adjustments, auxiliary aids, and/or
services. Specific reporting format is left to the professional, but the required components must be clearly
presented and easily discernable. Regardless of the format used, assessment reports must include all
information required by the Penn State Guidelines for documenting the student’s disorder. The guidelines
for documenting AD/HD can be found at the following web site:
http://www.equity.psu.edu/ods/guidelines/adhdguidelines.asp Not providing all information required may
prevent the student from receiving academic adjustments, auxiliary aids, and/or services from Penn State.

A summary of the guideline categories for documenting AD/HD is as follows:
   1. Presenting concerns at the time of evaluation;
   2. History (developmental, family, medical, psychosocial, psychological, pharmacological, educational,
      and employment);
   3. Psycho-educational testing;
   4. A DSM IV Diagnosis with a corresponding diagnostic code;
   5. Functional limitations; and
   6. Summary and recommendations.

In addition to the documentation guidelines for AD/HD, the student must have their provider fill out the
Verification Form for AD/HD. The Verification Form for AD/HD is not to be utilized in place of the
documentation requirements; rather, it is supplemental to a full neurological evaluation and report
from the evaluator.
Note to Provider:
Penn State would prefer to receive a typed version of this verification form. To make it easier for the
provider to type information on the form, an electronic version of this form can be obtained from the Office
for Disability Services’ (ODS) web site at the following address:
http://www.equity.psu.edu/ods/guidelines.asp . If the student is attending the University Park location, the
form should be returned to the ODS. If the student is attending another Penn State location, the form
should be returned to the DCL at the location. Information regarding the DCL at other PSU locations can
be found at: http://www.equity.psu.edu/ods/dcl.asp
                                                        Verification of Attention Deficit Hyperactivity Disorder   4

STUDENT’S NAME:
PSU ID #:                           If PSU ID is not known, fill in Social Security#:

Items 1 thru 14 must be completed in full. Professionals conducting the assessment and rendering
a diagnosis must be qualified to do so (e.g., a licensed neuropsychologist or a neurologist). It is
not appropriate for professionals to evaluate members of their family or others with which they
have personal or professional relationships. The provider signing this form must be the same
person answering the questions on the form below.


1. What is the student’s diagnosis (utilize DSM-IV codes)?


      [   ] 314.00   Predominantly Inattentive Type
      [   ] 314.01   Predominantly Hyperactive-Impulsive Type
      [   ] 314.01   Combined type
      [   ] 314.9    Not otherwise specified


   a. How long has the student had this disorder?


   b. What is the severity of the disorder?     Mild              Moderate                      Severe

       Explain the severity checked above:




   c. What is the expected duration?          Chronic                 Episodic                 Short-term

       Explain the duration checked above:




2. State the following:
   a. Date of first contact with student::

   b. Date of last contact with student::

   c. Date(s) current psycho-educational/psychological assessment was completed:




    d. Frequency of appointments with student (e.g., once a week, twice a month):
                                                      Verification of Attention Deficit Hyperactivity Disorder   5
3. Student’s History:

   a. Developmental History. Provide pertinent developmental information that was obtained from the
      student/parent(s)/guardian(s):




   b. AD/HD History: Evidence of inattention and/or hyperactivity during childhood and
      presence of symptoms prior to age seven years. Provide information supporting the diagnosis
      obtained from the student/parent(s)/teacher(s). Indicate the AD/HD symptoms that were present
      during early school years (e.g., day dreamer, spoke out of turn, was disruptive, difficulty learning to
      read, difficulty understanding directions, unable to sit still, often misplaced things, etc.):




   c. Family History. Provide pertinent information obtained from the student/ parent(s)/guardian(s)
      regarding the family’s medical and/or psychological history:




   d. Medical History. Provide pertinent medical information obtained from the student/
      parent(s)/guardian(s) (include any medical evaluations that ruled out medical causes of current
      symptoms):
                                                     Verification of Attention Deficit Hyperactivity Disorder   6
   e. Psychological History. Provide pertinent psychological history (include any psychological reports or
      testing utilized, if applicable):




   f. Pharmacological History. Provide pertinent pharmacological history, including an explanation of the
      extent to which the medication has mitigated the symptoms of the disorder in the past:




   g. Psychosocial History. Provide pertinent information obtained from the student/
      parent(s)/guardian(s) regarding the student’s psychosocial history (e.g., often engaged in verbal or
      physical confrontation, history of not sustaining relationships, history of employment difficulties,
      history of educational difficulties, social inappropriateness, history of risk-taking or dangerous
      activities, history of impulsive behaviors, etc.):




4. Student’s Current Symptoms and Concerns:

      a. Presenting Concerns Provide information regarding the student’s current presenting concerns:
                                                     Verification of Attention Deficit Hyperactivity Disorder   7
      b. Specific Symptoms:

         Please check all AD/HD symptoms listed in the DSM IV that the student exhibits:

         [ ] Inattention:
              [ ] often fails to give close attention to details or makes careless mistakes in schoolwork,
                   work or other activities
              [ ] often has difficulty sustaining attention in tasks or play activities
              [ ] often does not seem to listen when spoken to directly
              [ ] often does not follow through on instructions and fails to finish schoolwork, chores, or
                   duties in the workplace (not due to oppositional behavior or failure to understand
                   instructions)
              [ ] often has difficulty organizing tasks and activities
              [ ] often avoids, dislikes, or is reluctant to engage in tasks (such as schoolwork or
                   homework) that require sustained mental effort
              [ ] often loses things necessary for tasks or activities (e.g. school assignments, pencils,
                   books, tools, etc.)
              [ ] is often easily distracted by extraneous stimuli
              [ ] is often forgetful in daily activities

         [ ] Hyperactivity:
             [ ] often fidgets with hands or feet or squirms in seat
             [ ] often leaves (or greatly feels the need to leave) seat in classroom or in other situations in
                  which remaining seated is expected
             [ ] often runs about or climbs excessively in situations in which it is inappropriate (in
                  adolescents or adults, may be limited to subjective feelings of restlessness)
             [ ] often has difficulty playing or engaging in leisure activities quietly
             [ ] is often “on the go” or often acts as if “driven by a motor”
             [ ] often talks excessively

         [ ] Impulsivity
              [ ] often blurts out answers before questions have been completed
              [ ] often has difficulty awaiting turn
              [ ] often interrupts or intrudes on others (e.g. butts into conversations or games)


5. Provide Information regarding symptoms that cause impairment in two or more settings (e.g., work,
   home, school).
                                                        Verification of Attention Deficit Hyperactivity Disorder   8
6. Describe the differential diagnoses that were excluded. State the reasons for considering these
   diagnoses and the reasons for ruling them out.




7. List the student’s current medication(s), dosage, frequency, and adverse side effects (if applicable for
   the above-mentioned diagnosis).




   a. Are there significant limitations to the student’s functioning directly related to the
      prescribed medications?

             Yes                  No



   b. If yes, explain:




   c. Provide an explanation of the extent to which the medication currently mitigates the symptoms of the
      disorder.




    d. Was the student evaluated on or off medication?          On               Off              Both


8. Information has been provided regarding objective testing supporting the diagnosis of AD/HD (refer to
   PSU AD/HD guidelines Section IV, Documentation Requirements and Section D, Relevant Testing for
   complete information required or go to the ODS web site at:
    http://www.equity.psu.edu/ods/student/adhd_guidelines.asp). Data for all psycho-educational testing,
   objective measures of attention or discrimination and any other relevant objective measures must be
   attached to the verification form.

   Objective measures of attention or discrimination have been performed and attached:

    Yes                  No              If no, please explain:
                                                      Verification of Attention Deficit Hyperactivity Disorder   9
9. According to Penn State’s guidelines for AD/HD, information must be provided from current self-reports
   and observer reports in order to help determine whether an individual is likely to meet diagnostic
   criteria for AD/HD (e.g., the Conners Adult AD/HD Rating Scale, CAARS; the long version of the self-
   report form, CAARS-S: L; the observer form, CAARS-O: L; and the Brown Attention Deficit Disorder
   Scale). This information must be attached to the verification form.

    Current self-reports and observer reports have been administered and attached:

    Yes                  No             If no, please explain:




10. Provide information regarding the impact, if any, of the disorder on a specific major life activity
    (e.g., learning, eating, walking, interacting with others, etc.).




11. State the student’s functional limitations from the AD/HD, specifically in a classroom or educational
    setting:
                                                     Verification of Attention Deficit Hyperactivity Disorder   10
12. State specific recommendations regarding academic adjustments, auxiliary aids, and/or services for
    this student, and a rationale as to the reason these academic adjustments, auxiliary aids, and/or
    services are warranted based upon the student’s functional limitations (e.g., if a note-taker is
    suggested, state the reasons for this request related to the student’s disorder).




13. If current treatments (e.g., medications, therapy) are successful, state the reasons the above academic
    adjustments, auxiliary aids, and/or services are necessary?




The provider must also include any reports that provide additional related
information. The provider completing this form cannot be a relative of the student.
The provider signing this form must be the same person answering the questions on
the form above.


Signature of Provider: _________________________________________                      Date: ________________

License #: ______________________________                State: _________________________________

(Please Print or Type)

Name/Title:

Address:


Phone:



Revised December 14, 2004

				
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Description: VERIFICATION OF ATTENTION DEFICIT HYPERACTIVITY DISORDER