Autism Spectrum Disorder Verification Form
Disability Support Services (housed in the Academic Support Center of the Larrance Academic Center) is
committed to providing equal access and reasonable accommodations, where appropriate, for qualified disabled
students as covered under the Americans with Disabilities Act of 1990 (ADA), as amended, Section 504 of the
Rehabilitation Act of 1973 and other legal mandates. The ADA defines a disability as a physical or mental
impairment that substantially limits one or more major life activities. In addition, in order for a student to be
considered eligible to receive academic accommodations, the documentation must show functional limitations
that impact the individual in an academic setting. Documentation must be received in a timely manner (one
week prior to requested accommodation use) before accommodations can begin. The law stipulates that, in a
postsecondary setting, a student does not qualify for services until they have registered with the disability office
and have been certified for eligibility. Retroactive accommodations are not made.
The Academic Support Center requires current and comprehensive documentation in order to determine
appropriate accommodations. It is in the student’s best interest to provide recent and appropriate documentation
that is not more than 3 years old for a psychological disorder. The outline below has been developed to assist the
student in working with the treating or diagnosing healthcare professional(s) in obtaining the specific
information necessary to evaluate eligibility for academic accommodations.
A. The healthcare professional conducting the assessment and/or making the diagnosis must be qualified to
do so. The persons are generally trained, certified or licensed psychologists or members of a medical
specialty.
B. All parts of the form must be complete as thoroughly as possible. Inadequate information, incomplete
answers and/or illegible handwriting will delay the eligibility review process by necessitating follow up
contact for clarification.
C. The healthcare provider should attach any reports which provide additional related information (e.g.
psycho-educational testing, neuropsychological test results, etc.). If a comprehensive diagnostic report is
available that provides the requested information, copies of that report can be submitted for
documentation instead of this form.
D. After completing this form, sign it, complete the Healthcare Provider Information section on the last
page and mail or fax it to us at North Central College, Attn: Academic Support, 30 N. Brainard Ave.,
Naperville, IL 60540 or 630-637-5462. The information you provide will be kept in the student’s file at
ASC. This form may be released to the student at his/her request. In addition to the requested
information, please attach any other information you think would be relevant to the student’s academic
adjustment.
If you have any questions regarding this form, please call the ASC at 630-637-5266. Thank you for your
assistance.
Autism Spectrum Disorder Verification Form
Student Information
The first eight pages are to be completed by the student. Some of the questions may not apply to your
situation. Please label them “not applicable.”
Name: __________________________________________________________________
Date of Birth: ________________________
Student ID: ____________________
Year in School: _______________________
Local phone: (____) __________________ Cell phone: (____) ______________
Address: ________________________________________________________________
Academic Information
1. Provide a description of your diagnosis. What symptoms do you experience?
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2. What types of services/accommodations have you used in the past and were they helpful?
Services
Extended Time on Exams
Reader/Scribe
Books on CD
Notetakers
Tutoring
Personal Counseling
Used?
Helpful?
Comments
3. What are your academic strengths?
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4. What are your academic weaknesses?
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5. How does your disability impact you in a classroom setting (i.e. listening, note-taking,
communication, writing, computer skills, sitting or attendance)?
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6. How does your disability impact you on evaluations (e.g. tests, papers, oral reports or group
projects)?
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7. How does your disability impact you when doing out-of-class assignments (e.g., reading, writing,
calculating, typing, research)?
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8. What will impact your success in college? What barriers do you see in you being successful? (e.g.,
skills, motivation, goal-setting, confidence, outside commitments, etc.)
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9. List the accommodations you are requesting in an academic setting, if applicable.
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Medication
1. What medications are you currently taking?
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2. How will you obtain them while at College?
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Housing Needs
1. Describe your current living arrangement (i.e., with parents, in dorm, with roommate etc.)
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2. Where do you plan to live while attending college? With whom?
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3. Describe your living habits (i.e., privacy, personal space needs, orderliness, etc.)
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Support Network
1. Who will be the support persons available to you on an ongoing basis while you are at college?
Examples: parent, spouse, therapist/counselor, coach, etc.
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2. What kinds of things do these people currently provide for you (i.e., what roles do each play)?
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3. Do you obtain services from the Division of Rehabilitation Services? If so, what do they provide
for you?
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Sensory Integration
Are you sensitive to certain stimuli?
___ Lights or visual disturbance: __________________________________
___ Odors: ___________________________________________________
___ Noise: ___________________________________________________
___ Touch: ___________________________________________________
___ Tastes/Textures: ___________________________________________
___ Other…please explain._______________________________________
Stress Tolerance
1. What particular situations trigger a stress response in you?
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2. What do you do, or what will others see, when you become fearful, angry or frustrated?
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3. Do you use manipulatives, comfort objects or repetitive behaviors to reduce your stress or anxiety?
If so, please describe.
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Please rate on a scale from 1-10 your ability to manage the stress of the following day-to-day situations
you may encounter as a student.
“No big deal” = 1-2
“I’d be anxious but OK” = 5-6
“I would be very angry or scared and it would be impossible for me to continue” = 9-10
___ The seat you usually sit in is taken when you get to class.
___ You have to look for a different parking spot every day.
___ The professor has left a note on the classroom door explaining that class will be held in an
alternative building today.
___ You are called upon in class to discuss a reading with a student next to you.
___ The bookstore does not have the book you need when you arrive to purchase it.
___ Your professor announces a pop quiz when you enter the room.
___Your roommate ate food that belonged to you which was in your shared refrigerator.
___ The bus you are riding forgets to stop at your stop to let you off.
___ You must walk through a very crowded hallway every time you need to get to your classroom.
___ The grade you get on your first paper (you thought was A quality) is a C- and the professor
instructs you to see him about it.
Fine Motor/Dexterity
1. Do you use a computer? _________________________________________________
2. Do you own a laptop? __________________________________________________
3. Is your handwriting legible? Slow? ________________________________________
4. Do you take good notes during a lecture? ___________________________________
Spatial Issues
1. Do you have trouble recognizing people’s faces? _____________________________
2. Do you have difficulty navigating different environments or remembering directions? If so, what
strategies do you use to help you? (maps, photos, etc.)
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Social Issues
1. Do you prefer spending time with your friends or spending time alone?
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2. What activities do you like to do with others? (movies, computer games, baseball, etc.)?
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3. When interacting with others, do you have difficulty:
 monitoring your voice level?
 knowing when to start or stop talking?
 knowing how to begin, maintain or end a conversation?
 making eye contact with others while talking?
4. How do you prefer to communicate (email, phone, in person) with the following groups:
 instructors or support persons?

other students?

friends and/or family?
Time management/organization issues
1. Do you have difficulty starting projects or papers?
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2. Do you have trouble using or structuring free time?
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3. Do you have difficulty making appointments, remembering them or getting to them? If so,
describe.
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4. Do you use a planner, palm pilot or other organizational system?
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5. How do you decide on the importance or priority of tasks? (i.e. studying different subjects)
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6. Is your work/study area organized/neat or disorganized/messy?
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7. Do you have a particular hobby or specific area of interest? Please describe.
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Disclosure/Advocacy
1. Whom do you plan to inform of your diagnosis at North Central College?
_______________________________________________________________________________
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2. Are you able to talk with an instructor, staff or teaching assistants about the impacts of your
disability? _____________________________________________________
3. What do you think your greatest challenge or barrier to success at the College will be?
_______________________________________________________________________________
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4. Any additional information about yourself that you would like Disability Services to know:
_______________________________________________________________________________
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Autism Spectrum Disorder Verification Form
Authorization to Secure and Release Information
The release for information needs to be filled out by the student.
I, (student’s name) _______________________________, consent to have the Assistant Director of
the Academic Support Center at North Central College secure information from the following care
provider:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State/Zip: _________________________________________________________________
Phone: ________________________________________________________________________
I understand the information to be released includes any confidential information to further
understanding of the request for academic and other accommodations, up to and including medical and
psychological information and records. This information is used for the purpose of determining
reasonable accommodations while the above student is attending North Central College.
Student Signature: ____________________________________________ Date: _______________
Witness Signature: ____________________________________________ Date: _______________
This release is valid for no longer than 12 months from the date signed and can be revoked at any
time.
Autism Spectrum Disorder Verification Form
Student Information
Name: __________________________________________________________________
Date of Birth: ________________________
Student ID: ____________________
Year in School: _______________________
Local phone: (____) __________________ Cell phone: (____) ______________
Address: ________________________________________________________________
Provider Information
The following information needs to be filled out by a qualified provider. Please provide responses to
the following items by typing or writing clearly. Illegible forms will delay the documentation review
process for the student.
1. Date of Diagnosis: ______________________________________________
2. Date student was last seen: _______________________________________
3. DSM-V Diagnosis
a. Level I: ______________________________________________________
b. Level II: _____________________________________________________
c. Level III: ____________________________________________________
4. In addition to the DSM-V criteria, how did you arrive at your diagnosis?
Structured or unstructured interviews with the student
Interviews with other persons
Behavioral observations
Developmental history
Educational history
Medical history
Neuro-psychological testing. Date of testing: _______________________
Psycho-educational testing. Date of testing: ________________________
Standardized or non-standardized rating scales
Other: ______________________________________________________
Please attach any relevant documentation.
5. What is the severity of the condition? Please check one:
mild
moderate
severe
Explain severity:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
6. What is the expected duration of this disability?
_______________________________________________________________________________
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7. Major Life Activities
Please check which of the following major life activities listed above are affected because of
the impairment. Indicate limitations.
Life Activity
Concentrating
Memory
Eating
Social Interactions
Self Care
Regular Attendance
Keeping Appointments
Stress Management
Managing internal distractions
Managing external distractions
Sleeping
Organization
Limitation
Not a limitation
Not applicable
8. Please describe the student’s symptoms relating to this diagnosis.
_______________________________________________________________________________
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9. What specific symptoms does the student have that might affect the student’s academic
performance?
_______________________________________________________________________________
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10. Describe any situations or environmental conditions that might lead to an exacerbation of the
condition.
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11. Is the student currently receiving therapy or counseling?
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12. What medications is the student currently taking? How effective is the medication? How might
side effects, if any, affect the student’s academic performance?
_______________________________________________________________________________
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13. Please state specific recommendations regarding academic accommodations for this student,
and a rationale as to why these accommodations/adjustments/services are warranted based upon
the student’s functional limitations. Indicate why the accommodations are necessary.
_______________________________________________________________________________
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14. Are there other associated disabilities? If so, what are they? Please describe these conditions
and any functional limitations.
_______________________________________________________________________________
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Provider Information
Provider Signature: ________________________________ Date: _______________
Provider Name (print): __________________________________________________
Title: ________________________________________________________________
License or Certification #: _______________________________________________
Address: _____________________________________________________________
Phone: (_____) _____________________ Fax: (____) ________________________
Important: After documentation is reviewed, ASC will send an email notification to the student’s
NCC email account, (e.g. jdoe@noctrl.edu), acknowledging the receipt of documentation and
eligibility status. Prospective students that do not yet have a NCC email account will be notified
via paper letter sent to their home address.