Services for Students with Disabilities 1717 S. Chestnut Ave. Fresno, CA 93702-4709 559-453-2247 wwwfresno.edu/disability-services Verification of Disability Student’s Name: Date: Address: Student ID #: MUST BE COMPLETED BY A LICENSED PROFESSIONAL1 1. Description of disability: Learning Disability Speech/language Impairment Mobility Impairment Psychological Disability 2. Condition is: 3. Duration of disability: ADD/ADHD Autism Hearing Impairment Visual Impairment Chronic Illness Dietary Traumatic Brain Injury (including concussion) Other (please describe) Stable Prone to exacerbation Permanent/chronic Temporary (estimated duration of disability) __________________ 4. Diagnosis/relevant medical history: _______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. Recommended services/accommodations: Educational Activity Writing in-class notes and assignments Seeing or visually processing text Hearing lectures and discussions Taking tests Using standard classroom curriculum and format Revised on 7/24/2016 9:34 PM Recommended Accommodations2 Note-taker Permission to record lectures Alternate format text Text-to speech software Preferential seating Oral description of the whiteboard Assistive listening device Sign language or oral interpreter Real time or closed/open captioning Preferential seating Extended time o 1.5 X o 2X Distraction-reduced setting Breaks Calculator Memory aids Assistive technology in classroom Permission to stand, move, leave briefly Lab assistant Personal attendant Leniency with attendance Extended due dates 219538918 Campus Facility and Services Facility Housing Emotional Support Animal (ESA) Meal plan/dietary Recommended Accommodations2 Padded/ergonomic chair Separate table and chair On-campus transportation Other Single room Wheel-chair/handicap accessible room Ground-floor room Quiet room Personal attendant Other ________________________ An ESA alleviates the following symptoms(s) or effect(s): o o o o Full meal plan exemption* Reduction in meal plan* o 140 block o 70 block *Indicate the specific reason for the meal plan accommodation: Food allergies/sensitivities (e.g. peanuts, lactose intolerant, gluten-free, etc.). Please list: o o o o Dietary requirements (e.g. high protein, high fiber, etc.) Please list: o o o Other ____________________________ Print name and title:______________________________________________________________ Signature:__________________________________________ Date:_____________________ 1 A business card or script must be attached for this verification to be valid. Additional documentation may be requested to support specific requested accommodation. 2 Return Address: Melinda Gunning/ Services for Students with Disabilities 1717 S. Chestnut Ave. #13 Fresno, CA 93702 Revised on 7/24/2016 9:34 PM 219538918