Mobility Disability 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 5 years old for physical disabilities. 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.
Mobility Disability Verification Form
Student Information
The first three 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: ________________________________________________________________
1. Provide a description of your diagnosis. What symptoms do you experience?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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?
_______________________________________________________________________________
_______________________________________________________________________________
4. What are your academic weaknesses?
_______________________________________________________________________________
_______________________________________________________________________________
5. How does your disability impact you in a classroom setting (i.e. listening, note-taking,
communication, writing, computer skills, sitting or attendance)?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6. How does your disability impact you on evaluations (e.g. tests, papers, oral reports or group
projects)?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. How does your disability impact you when doing out-of-class assignments (e.g., reading, writing,
calculating, typing, research)?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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.)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
9. List the accommodations you are requesting in an academic setting, if applicable.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Mobility Disability 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.
Mobility Disability 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. What is the diagnosis, date of diagnosis, and last contact with student?
_______________________________________________________________________________
_______________________________________________________________________________
_________________________________________________________________________
2. Please describe the progression of this condition if applicable.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3. Describe the symptoms that meet the criteria for the diagnosis. Also, describe how this mobility
disability may affect this student both academically and/or physically (functional limitations).
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4. List current medications, dosage, frequency, and adverse side effects.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
5. What recommendations do you have regarding accommodations (i.e. extra time for exams,
note-taker, disability parking). Please describe your rationale for the accommodations you have
recommended.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6. Are there other associated disabilities? If so, what are they? Please describe these conditions
and any functional limitations.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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