CRAFTON HILLS COLLEGE DISABLED STUDENTS PROGRAMS & SERVICES (DSPS)
VERIFICATION OF DISABILITY
The student named below has requested services/accommodations at Crafton Hills College.
__________________________________________________________________
Name: Last,
First,
MI
_______________________________________
Signature
Date
_________________________________________________________________
Date of Birth
ID# or SS#
_______________________________________
Phone #
Crafton College agrees to use the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services
provided by the Disability Programs & Services. Personal information recorded on this form will be kept confidential in order to protect against unauthorized
disclosure. I hereby consent for Chaffey College DPS to contact certifying professional for additional information if needed.
This portion to be filled out by a licensed professional.
1.
Description of Primary Disability:





Acquired Brain Impairment
 Intellectual Disability
 Deaf/Hard of Hearing
Learning Disability
 Mobility Impairment
 Autism / Asperger’s
Speech/Language
 Visual Impairment
 ADD/ADHD
Mental Health: DSM-IV AXIS I & II Diagnosis and Code(s): ___________________________________________________
Other
2. Functional/Educational Limitations (Certifying Professional must INITIAL next to each limitations resulting from the
disabilities above):
____ Gross motor skills
____ Fine motor skills
____ Attention
____ Concentration
____ Student may have to leave room intermittently
____ Requires highly structured learning environment
____ Long term memory
____ Short term memory
____ Walking
____ Difficulty sitting for extended times
____ Difficulty standing for extended times
____ Difficulty using dominant hand
____ Processing visual information
____ Processing auditory information
____ Receptive language
____ Expressive language
____ Other:________________________________________
3. Recommended services/accommodations: _____________________________________________________________________
____________________________________________________________________________________________________________
4. This disability is:
 Permanent/Chronic
 Temporary: less than 45 days
5. This disability is:
 Observable
 Not observable
 Temporary: 45 days or greater
Licensed Professional
Print Name & Title ____________________________________________________
MAIL, FAX, OR DELIVER THIS FORM TO:
Signature ____________________________________________________________
Crafton Hills College
Disabled Student Programs & Services
11711 Sand Canyon Rd.
Yucaipa, CA 92399
Fax: (909) 794-3684
909-389-3325
Address _____________________________________________________________
Phone ______________________________________________________________
Documentation Requirements for Verification of Disability
To receive services through Crafton Hills College DSPS, a student must provide current documentation of a verified disability
(including educational limitations and recommended services) to DSPS. Documentation should be most recent available.
Disability & Definition
Required Documentation & Appropriate Professional
High school students, submit most recent Individual Education
Plan & Psychological Evaluation and:
Acquired Brain Injury (deficit in brain functioning
resulting in loss of cognitive, communicative, motor,
psychological, and/or sensory/perceptual abilities and
limits the student’s ability to access the educational
process)

Intellectual Disability (significant limitations in both
intellectual functioning and in adaptive behavior that
affect and limit the student’s ability to access the
educational process – below average intellectual ability
and disability originated before the age of 18)
Deaf & Hard of Hearing (total or partial loss of hearing
function that limits the student’s ability to access the
educational process)


Cognitive rehabilitation report/neurological
assessment/medical report documenting the disability
Licensed Professional (Neurologist, Physician)

Regional Center certification and/or psychological report
(usually WAIS IV or WISC IV) documenting the disability
DSPS Coordinator or ID Specialist verifying documentation


Current audiogram documenting the disability
Medical Doctor or Licensed Ear Professional
Learning Disability (persistent condition of presumed
neurological dysfunction that limits the student’s ability
to access the educational process - average to above
average intellectual ability; statistically significant
processing deficit; statistically significant aptitudeachievement discrepancy)
Physical Disability (limitation in locomotion and/or
motor function and limits the student’s ability to access
the educational process)
Mental Health Disability (persistent psychological or
psychiatric disability, or emotional or mental illness that
limits the student’s ability to access the educational
process)
Attention-Deficit Hyperactivity Disorder (ADHD)
(neurodevelopmental disorder that is a persistent deficit
in attention and/or hyperactive and impulsive behavior
that limits the student’s ability to access the educational
process)
Blind and Low Vision (level of vision that limits the
student’s ability to access the educational process)


Psychological report documenting the disability
LD Professional using the CA Community College LD Eligibility
Model
DSPS LD Specialist certifies documentation from a referring
agency
Autism Spectrum (neurodevelopmental disorders
described as persistent deficits which limit the student’s
ability to access the educational process – symptoms
must have been present in early developmental period)
Other Disability (other health conditions and/or
disabilities that affect a major life activity not previously
defined and limit the student’s ability to access the
educational process)



Medical report documenting the disability
Physician


Psychological report documenting the DSM Code and Axis
Licensed Professional (Psychiatrist, Psychologist, MFT, Social
Worker)


Medical report documenting the disability
Physician or Licensed Professional


Current vision test documenting the disability
Physician or Licensed Vision Professional


Medical report documenting the disability
Physician or Licensed Professional


Medical or professional report documenting the disability
Physician or Licensed Professional
Definitions are according to Title 5 of the California Code of Regulations for California Community Colleges.