Augsburg University
Center for Learning and Accessible Student Services
Verification of Disability

The student named below is requesting accommodations due to the impact of a disability. To evaluate that request, our office is asking that the following form be completed by a qualified professional who has first-hand knowledge of the student's condition and is an impartial individual not related to the student. 

The provision of academic adjustments and/or reasonable accommodations is based on an assessment of the interaction between the current impact of the student’s disability and barriers they may face in the postsecondary environment as a result. 

It should be noted that academic accommodations are intended to ensure access to educational opportunities for students with disabilities, not to make adjustments that would fundamentally alter the nature of courses, course components, or course requirements.

The completed form can be emailed to class@augsburg.edu, faxed to (612)330-1137,
or mailed to the CLASS Office, 2211 Riverside Ave, CB#57, Minneapolis, MN  55454.

Student: Last Name				 		 First    			 MI	

Date of Birth  _____/_____/_____		    	Phone 						

Certifying Professional  (This section is to be completed by a qualified professional)

Print Name												

Professional Title  											

License/Certification Number and Issuing State 								

Agency 												

Address  												

City  							  State  		  Zip Code  			

Phone  								Fax  					

Signature									 Date 			

Diagnosis

Please attach any assessment reports and/or scores from any diagnostic tests that were used to support these diagnoses. 

Diagnosis/es_____________________________________________________________

Date of Diagnosis: _______/_______/_______

Initial contact with student: _____/_____/_____ Last contact with student:  ____/_____/_____

Level of the severity of the disorder (circle):   Mild	   Moderate	Severe

Expected duration (circle): 	Permanent	Chronic/recurring	Temporary

Description of symptoms: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please describe the settings in which these symptoms have been most evident: 
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If this student is taking medication for their disability, describe the medication(s), side effects, and potential impact on academic work: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Impact of Condition in Educational Environment

How does this condition affect this student’s ability to learn or meet the expectations of a college environment?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide any additional information you believe would be helpful so that we can provide effective support/accommodations, (i.e. threat to self or others, history of hospitalizations, any known effective academic adjustments).  Attach additional sheets as necessary and include results of related assessments.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your assistance in completing this form.