One Otterbein University
Westerville, OH 43081-2006
TEL (614) 823-1610
FAX (614) 823-1983
www.otterbein.edu
Academic Support Center
VERIFICATION OF A COMMUNICATION/LANGUAGE DISORDER
The Disability Services Coordinator at Otterbein University provides services to students with
diagnosed Language Disorders. In order to determine eligibility of services and appropriate
accommodations, this office requires current and comprehensive documentation of this disorder from
the licensed Audiologist or Speech Pathologist.
Please print legibly or type answers to the following questions.
Student Name:
Date:
Student ID #:
1.
What is the diagnosis, date of diagnosis, and the last contact with the student?
2.
What instruments and procedures were used to diagnose the disorder?
3.
Describe symptoms that meet the criteria for this diagnosis and report all test results.
Please attach diagnostic report if possible.
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4.
Describe the functional limitations of this disorder for this student in an educational
setting.
5.
What recommendations do you have regarding academic accommodations and your
rationale for these recommendations?
6.
Briefly describe current treatment plan and assessment of the duration of this disorder
if the condition is remediable.
Signature:
Date:
Provider Name (printed):
Title:
License Number (if applicable)
Address:
City, State, Zip
Phone Number:
Fax Number:
Email Address:
Please return this information to:
Kera McClain Manley
Disability Services Coordinator
Otterbein University
Westerville, OH 43081
Phone: 614-823-1618
FAX: 614-823-1618
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