HARFORD COMMUNITY COLLEGE
CERTIFICATION OF ONE OF THE FOLLOWING CONDITIONS:
MOBILITY, PHYSICAL/HEALTH or NEUROLOGICAL
The student named below has applied for services from Harford Community College’s Disability Support Services Office.
In order to be able to determine eligibility and what, if any accommodations are warranted, documentation or
additional documentation is needed.
Under the Americans with Disabilities Act (ADA) of 1990 and Section 504 of the Rehabilitation Act of 1973, individuals
with disabilities are protected from discrimination and may be entitled to reasonable accommodations. To establish
that an individual is covered under the law, documentation must indicate that a specific disability exists and that the
identified disability limits one or more major life activities (e.g. learning). A diagnosis of a disorder in and of itself does
not automatically qualify an individual for accommodations. The documentation must also support the request for
accommodations and explain how the disability impacts learning.
Please complete this form and return by mail or fax to:
Harford Community College
Disability Support Services
401 Thomas Run Road
Bel Air, Maryland 21015
Attn: ___________________________
Fax: 443.412.2200
Date: _______________
Clinician’s Name: ___________________________________ Credentials: ________________________
Address: _____________________________________________________________________________
City: ______________________ State: ___________ Zip: ________________ Phone: ________________
Signature: ________________________________
All items must be completed in full. Professionals conducting the assessment and rendering a diagnosis must be
qualified to do so (e.g. a licensed physician). The provider signing this form must be the same person answering the
questions on the form below.
Please note: it is NOT appropriate for professionals to evaluate members of their family or others with whom they
have personal or business relationships.
Name of Student: __________________________________________ Date of Birth: ________________
I, _________________________________, authorize a release of information, allowing the Disability Support Services
Office at Harford Community College to contact the physician completing this form to obtain additional information or
clarification in order to determine reasonable accommodations.
_________________________________________________
Signature
Effective 8/21/13
_______________
Date
Office of Disability Support Services
DISABILITY RELATED INFORMATION
1) What is the student’s condition? _________________________________________________________________
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2) How long has the student had this condition? _____________________________________________________
a. Please check the severity of the condition.
 Mild
 Moderate
 Severe
b. Please explain the severity checked above. __________________________________________________
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3) Please check to indicate the expected duration.
 Chronic
 Episodic
 Short – term
a. Please explain the duration checked above. _________________________________________________
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4) Please check to indicate if the student able to ambulate.
 Yes
 No
a. If the answer above is yes, how far can the student ambulate without stopping or resting (e.g., one
block, one mile, etc.)? ___________________________________________________________________
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5) Can the student negotiate stairs or is an elevator required? ___________________________________________
6) Is the student able to write without assistance? Please check.
 Yes
 No
a. If no, what type of assistance is recommended (e.g., scribe)? ___________________________________
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7) Is the student able to perform activities of daily living (e.g. use the restroom, shower, prepare meals, select
clothing, pay bills, etc.)? Please check.
 Yes
 No
a. If no, explain which activities of daily living the student is unable to do independently.
___________________________________________________________________________________________
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8) Please check to indicate if the student is able to follow simple directions (e.g., two step directions)?
 Yes
 No
a. If no, please explain. ____________________________________________________________________
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9) State frequency of appointments with student (e.g. once weekly, once monthly). _________________________
a. Date of first contact with student: ___________________________
b. Date of last contact with student: ___________________________
10) Dates and results of diagnostic assessment(s) ______________________________________________________
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HISTORY
Please describe the following:
DEVELOPMENTAL HISTORY: Please provide pertinent developmental information that was obtained from the student or
parent(s)/guardian(s):
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FAMILY HISTORY: Please provide pertinent information regarding the family’s medical and/or psychological history:
__________________________________________________________________________________________________
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MEDICAL HISTORY: Please provide pertinent medical information, including any medical evaluations that rule out
medical causes of the current symptoms:
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PSYCHOLOGICAL HISTORY: Please provide pertinent psychological history, including any evaluations that rule out
psychological causes of the current symptoms:
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PHARMACOLOGICAL HISTORY: Provide pertinent pharmacological history, including an explanation of the extent to
which the medication has alleviated the symptoms of the disorder in the past.
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CURRENT SYMPTOMS AND CONCERNS
PRESENTING CONCERNS: Please provide information regarding the student’s current presenting concerns.
__________________________________________________________________________________________________
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SPECIFIC SYMPTOMS: Please provide information regarding the student’s current symptoms.
__________________________________________________________________________________________________
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Please provide information regarding the student’s symptoms that cause impairment in one or more settings (e.g. work,
home, school). ______________________________________________________________________________________
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MEDICATION:
Please list current medication, including dosage and frequency:______________________________________________
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Are there significant limitations to the student’s functioning directly related to the prescribed medications? Please
check.
 Yes
 No
If yes, please explain: ________________________________________________________________________________
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Please provide an explanation of the extent to which the medication currently mitigates the symptoms of the disorder.
__________________________________________________________________________________________________
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FUNCTIONAL LIMITATIONS:
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.). ___________________________________________________________________
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Does the student utilize a wheelchair, crutches, cane, or other device to assist with mobility? If so, please state device.
__________________________________________________________________________________________________
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Please check to indicate if the student requires use of a service animal?  Yes
 No
If yes, what tasks does the animal perform that the student cannot perform for him or herself?
__________________________________________________________________________________________________
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Please check to indicate if the student currently utilizes adaptive or assistive technology?
 Yes
 No
If so, please state what technology and indicate if the technology is utilized in an educational, home, or work setting.
__________________________________________________________________________________________________
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State a rationale as to how the assistive or adaptive technologies are warranted based upon the student’s functional
limitations (e.g., if a screen reader is suggested, state the reasons for this request related to the student’s disorder). Be
as specific as possible, including brand name and model number.)
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State the student’s functional limitations from the condition, specifically as they apply to a classroom or educational
setting.
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ACCOMMODATIONS
Please make recommendations for accommodations in an educational setting (e.g. use of interpreter, real-time
captioning, hearing aids, microphone, etc.) and indicate the reason these accommodations are warranted if the current
treatments are successful. Specify how the accommodations and strategies directly relate to symptoms and/or
functional limitations.
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