Fillable Verification Form Specific Learning Disabilities Bucks County Community (Bucks County Community College)

Fill Online, Printable, Fillable, Blank Verification Form Specific Learning Disabilities Bucks County Community (Bucks County Community College) Form

Use Fill to complete blank online BUCKS COUNTY COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Verification Form Specific Learning Disabilities Bucks County Community (Bucks County Community College)

On average this form takes 22 minutes to complete

The Verification Form Specific Learning Disabilities Bucks County Community (Bucks County Community College) form is 6 pages long and contains:

  • 1 signature
  • 17 check-boxes
  • 78 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bucks County Community College

BROWSE BUCKS COUNTY COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Newtown Campus • Student Services Center • Rollins Building • 275 Swamp Road • Newtown • PA • 18940
(215) 968-8182 • (215) 968-8033 fax • accessibility@bucks.edu • http://www.bucks.edu/student/accessibility/
Adapted by permission from The Pennsylvania State University
Verification Form
Specific Learning Disabilities
Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Specific Learning Disabilities
to obtain current information from a qualified practitioner (e.g., psychologist, neuropsychologist) regarding a student’s learning
disorder symptoms and their impact on the student and his or her need for accommodations. This Verification Form should
supplement information that is provided in other reports, including full neuropsychological or psychoeducational evaluations or
secondary school documentation. Any documentation, including this Verification Form, must meet Bucks County Community
College’s TAO guidelines for Specific Learning Disabilities. The person completing this form may not be a relative of the student or
hold power of attorney over the student.
A summary of the guideline criteria for documenting Specific Learning Disabilities can be found at the following web site:
http://www.bucks.edu/student/accessibility/student-info/. A summary of the guideline criteria for documenting Specific Learning
Disabilities is as follows:
1. Persistent learning difficulties and academic performance below expectations as measured by objective and statistically sound
assessments of aptitude and achievement
2. Educational history of learning difficulties
3. Functional limitations affecting an important life skill, including academic functioning
4. Exclusion of alternative diagnoses or attributing factors
5. Summary and recommendations
Section I: Student Information (Please type information or print legibly)
Student Name:
Last
First
Middle
Student ID:
Cell Phone:
Bucks Email:
Permanent Street
Address:
City:
State:
Zip:
Local Street
Address:
City:
State:
Zip:
Section II: Provider Section (Please type information or print legibly)
A. Contact with the Student:
Date of initial contact with the student:
Date of last contact with the student:
B. Diagnosis Information:
1. Educational History
Does the student have an educational history of a learning disorder?
Yes
NO
Approximately at what age or grade did the student start to exhibit apparent difficulty
learning academic skills?
What date was the student diagnosed with specific learning disability
symptoms?
Month
Year
Verification Form: Specific Learning Disabilities 2
The Accessibility Office Bucks County Community College
Specific Learning Disabilities Verification Form
What date or grade was the student diagnosed with a learning disorder?
Please include any historical information relevant to the student’s learning disorder and associated
functioning (e.g., developmental, familial, medical, pharmacological, psychological, psychosocial).
2. Impact of Learning
Has the student demonstrated a persistent difficulty learning academic skills (for at
least
Yes
NO
six months) despite targeted intervention(s) in the area(s) of academic difficulty?
Please check all areas of the student’s documented academic skill difficulties that are substantially below
expectations given the student’s age:
Word decoding and word reading fluency
Reading comprehension
Spelling
Writing difficulties such as grammar, punctuation, organization, and clarity
Number sense, fact and calculation
Mathematical reasoning
Did you use objective and statistically sound assessments to evaluate the student’s
Yes
NO
learning difficulties?
If yes, please provide information regarding the student’s global intellectual functioning and current academic
functioning as measured by aptitude and achievement tests respectively. This information can be attached to
this Verification Form if contained within a neuropsychological or psychoeducational evaluative report (please
include this report with the Verification Form).
Aptitude:
List the name of the comprehensive and current aptitude/cognitive instrument administered
List the standard scores per subtest; and (c) the percentiles per subtest
Verification Form: Specific Learning Disabilities 3
The Accessibility Office Bucks County Community College
Specific Learning Disabilities Verification Form
Achievement:
List the name of the comprehensive and current achievement battery administered
List the standard scores per academic area subtest
List the percentiles per academic area subtest
If no, how did you reach your conclusion about the learning disorder and necessary interventions and
academic accommodations?
3. Functional Impairment:
Is there clear evidence that the student’s learning difficulties are interfering with or reducing the quality of
at least one of the following, including academic functioning?
Environmental Functioning:
School functioning:
Social functioning:
Work functioning:
Verification Form: Specific Learning Disabilities 4
The Accessibility Office Bucks County Community College
Specific Learning Disabilities Verification Form
Please check all that can be attributed to the student’s academic and learning difficulties:
Intellectual disability
Visual or hearing impairment
Psychological disorder (e.g., depression, anxiety, etc.)
Neurological disorder
Psycho-social difficulty
Language differences (i.e., English as a second language)
Lack of access to adequate instruction
6. DSM Codes: Please include all pertinent diagnoses or rule-out diagnoses using DSM codes.
Please include all pertinent diagnoses or rule-out diagnoses using DSM codes.
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V (GAF):
C. Medications:
1.
Is the student currently taking medication(s) for SPECIFIC LEARNING DISABILITIES
symptoms?
Yes
NO
2.
If yes, please provide information below for each medication the student is currently prescribed:
Medication Dosage Frequency (e.g., Adderall 5 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Medication Dosage Frequency (e.g., Adderall 5 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
Verification Form: Specific Learning Disabilities 5
The Accessibility Office Bucks County Community College
Specific Learning Disabilities Verification Form
Medication Dosage Frequency (e.g., Adderall 5 mg 1 x daily):
Date Prescribed:
Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):
D. Functional Limitations and Recommended Accommodations:
1. Please list the student’s current Specific Learning Disabilities symptoms and then indicate what reasonable
academic accommodations would mitigate the symptom listed.
2. Sample: A student requires great effort to read class materials and completes reading assignments at a slow
rate.
Symptom: (Example)
Slow, effortful reading
Recommended Reasonable Accommodation(s):
Textbooks and written classroom materials in alternative format to be read by text-to-speech software
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Symptom:
Recommended Reasonable Accommodation(s):
Verification Form: Specific Learning Disabilities 6
The Accessibility Office Bucks County Community College
Specific Learning Disabilities Verification Form
Section III: Provider’s Certifying Professional Information:
(Please type information or print legibly)
Professionals conducting the assessment, rendering a diagnosis, and providing recommendations for reasonable
accommodations must be qualified to do so (e.g., psychologist, neuropsychologist). The provider signing this form must
be the same person answering the above questions.
Provider’s Name:
Last
First
Middle
Credentials:
License Number:
Phone Number:
Practice Street
Address:
City:
State:
Zip:
May this completed Verification Form be released to the student?
Yes
NO
Provider Signature:
Date:
Section IV: Submitting this Form
This form should be returned to the Accessibility Office (TAO) at Bucks County Community College where the
student is enrolled. All forms need to be submitted at the Newtown campus. Please see the following
methods of submission of this form:
Email: accessibility@bucks.edu
Fax: (215) 968-8033
USPS: Bucks County Community College
Attention: The Accessibility Office
275 Swamp Road
Newtown, Pennsylvania 18940
Physical Newtown Campus
Drop Off: Rollins Center • Student Services Office • Room 001
Information regarding the Accessibility Office (TAO) at Bucks County Community College can be found at
http://www.bucks.edu/student/accessibility/. Please visit our website for the latest information and updates
as they are made available. If you have any questions, please feel free to call us (215) 968-8182.
Bucks County Community College does not discriminate in its educational programs, activities or employment practices based on race, color, national origin, sex,
sexual orientation, disability, age, religion, ancestry, veteran status, union membership, or any other legally protected category.
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Verification Form Specific Learning Disabilities Bucks County Community (Bucks County Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document