Camp Community College – Impairment and Disability Assessment

Impairment and Disability Assessment

This form must be completed by the physician or other appropriate licensed professional qualified to evaluate the specific disability. Complete all fields across both pages, then click Print to PDF to save and submit to the appropriate office.

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STUDENT: This form must be completed by the physician or other appropriate licensed professional qualified to evaluate the specific disability.

TO THE LICENSED PROFESSIONAL: To ensure the provision of reasonable and appropriate services and/or accommodations for students with medical disabilities, current and comprehensive documentation must be provided.

Student Information

Student Name

Date of Most Recent Evaluation

Clinical Information

Diagnosis and Relevant DSM or ICD Code (if applicable)

Description of the Diagnostic Method and Criteria

Description of Presenting Symptoms

Description of the Potential Impact of the Disability on the Student's Academic Performance

Description of Expected Progression or Stability of the Disability and How It May Impact the Student During Their Enrollment

Is the student currently taking medication for this disorder?

Yes No

If YES, does this medication have the potential to impair cognitive functioning or ability to perform safe patient care?

Yes No

Recommended Academic Adjustments, Auxiliary Aids, and/or Accommodations Based on the Diagnosed Disability

I certify the above to be true and correct

Signature of Professional Completing This Form

License Number

Date

Printed Name / Credentials

Phone

Business Address

Major Life Activity with Which This Condition Interferes

Others

Recommended Accommodations

Please check any accommodations recommended to help the student compensate for the aforementioned disability within the context of the college environment.

Modify Presentation of the Material

Allow student to obtain information utilizing:

Cassette Tape Recorders Administer test orally Computer / iPads (for writing) Duplicate materials in large print Note Taker Other:

Modify the Environment

Provide Opportunities for movement Allow student to sit in the front and/or center of classroom Permit student to sit at specially designed tables or chairs Instructor may arrange for a test to be proctored by the Test Administrator to decrease distractions. Other:

Modify Time Demands

Increase amount of time by percent to complete assignments/tests Give student a specific task to perform with specific time limits. (Not to exceed grading period or semester) Other:

Additional details (if needed)

IMPAIRMENT AND DISABILITY ASSESSMENT | K. Worth 4/2024

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