VINCENNES UNIVERSITY
VERIFICATION OF DISABILITY FOR DETERMINATION OF ACCOMMODATIONS
PLEASE TAKE THIS COVER SHEET TO YOUR MEDICAL PROVIDER/PROFESSIONAL TO OBTAIN RELEVANT
DOCUMENTATION. A good match between the credentials of the medical provider/professional making the diagnosis
and the condition being reported is expected. For example:
Learning Disabilities: Licensed Psychologist, School Psychologist or Neuropsychologist
Attention Deficit Disorders: Licensed Psychologist, Psychiatrist or Physician
Psychiatric Impairments: Licensed Clinical Social Worker, Psychologist or Psychiatrist
Medical/Health/Physical Disabilities: Physician/Medical Specialist within area of Disability
Student’s Full Name _________________________________________________________________________________
VU Student ID Number (A#) or Birthdate ____________________________________________________________
One of the following must be attached to this cover sheet to assist us in determining the most appropriate
accommodations for this student’s disability. For Attention Deficit Disorders, Psychiatric Impairments, or
Medical/Health/Physical Disabilities, you may use either of the (2) two documentation options listed below.
For Learning Disabilities, please only use the “Diagnostic Test Report” option.
Diagnostic Narrative in letter format, typed on letterhead, with an original signature. We will not accept a
Diagnostic Narrative for the verification of a specific learning disability. Please include in the narrative:
-a specific diagnosis and, if you provided the diagnosis, the methods used to diagnose the disability
-the CURRENT, specific symptoms manifested by this individual
-a discussion of the ways this disability prevents full participation in classes
Diagnostic Test Report typed on letterhead, with an original signature. Please include in the report:
-a list of all tests administered with all test scores and interpretations
-the identification of global intelligence (IQ,) if identifying a learning disability
-assessments of achievement and information processing, if identifying a learning disability
-a diagnostic summary
-the CURRENT, specific symptoms manifested by this individual
-a discussion of the ways this disability prevents full participation in classes
If available, please attach the student’s latest IEP or school plan
Specialist’s Printed Name ____________________________________________________________________________
Specialist's Signature ________________________________________________________________________________
Specialty Area ______________________________________________________________________________________
Contact Telephone Number ________________________________________________ Date _____________________
Please forward all documentation to Leslie M. Smith, Director, Disability Services by one of the following:
lmsmith@vinu.edu
Effective 10-31-14
~OR~
1002 N. First St, Vincennes, IN 47591
~OR~
Confidential Fax: 812/888-2087