Attention Deficit/Hyperactivity 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 limitation(s) 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 diagnosis of ADHD. 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 to us at North Central College, Attn: Academic Support, 30 N. Brainard
Ave., Naperville, IL 60540 or fax it to 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.
Attention Deficit/Hyperactivity Disorder 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?
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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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Attention Deficit/Hyperactivity 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 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.
Attention Deficit/Hyperactivity 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. DSM-V diagnosis:
314.00
Predominantly Inattentive
Predominantly Hyperactive-Impulsive
314.01 Combined Type
314.9 Not Otherwise Specified
2. In addition to DSM-V criteria, how did you arrive at your diagnosis?
Behavioral observations
Developmental history
Rating scales
Medical history
Structured or unstructured clinical interview with the student
Interviews with other persons
Neuropsychological testing (dates of testing) __________________________
Other (please specify): ____________________________________________
Please attach diagnostic reports of testing or the clinical interview
3. Date of diagnosis: ______________________________
Date of first contact with student: __________________
Date of last contact with student: __________________
4. Student’s History:
a. ADHD History: Evidence of inattention and/or hyperactivity during childhood and
presence of symptoms prior to age seven. Provide information supporting the diagnosis
obtained from the student, parents, and teachers. Indicate the ADHD symptoms that
were present during early school years (e.g., spoke out of turn, unable to sit still,
difficulty following directions).
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b. Psychosocial History: Provide relevant information obtained from the student/parents
regarding the student’s psychosocial history (e.g. often engaged in verbal or physical
confrontation, history of educational difficulties, history of risk-taking, history of
impulsive behavior, social inappropriateness).
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c. Pharmacological History: Provide relevant pharmacological history including an
explanation of the extent to which the medication has mitigated symptoms of the
disorder in the past. Also include any current medication that the student is currently
prescribed including dosage, frequency of use, adverse side effects and effectiveness.
_________________________________________________________________________
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d. Educational History: Provide a history of the use of any educational accommodations
and services related to this disability.
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5. Student’s Current Specific Symptoms: Please check all ADHD symptoms listed in the DSM-IV
that the student currently exhibits:
Inattention:
often fails to give close attention to details or makes careless mistakes in school work,
work or other activities
often has difficulty sustaining attention in tasks or recreational activities
often does not seem to listen when spoken to directly
often does not follow through on instructions and details to finish schoolwork, chores or
duties in the workplace (not due to oppositional behavior or failure to understand
instructions)
often has difficulty organizing tasks and activities
often avoids, dislikes or is reluctant to engage in tasks (such as schoolwork or
homework) that require sustained mental effort
often loses things necessary for tasks or activities (e.g., school assignments, pencils,
tools, etc.)
is often easily distracted by extraneous stimuli
often forgetful in daily activities
Hyperactivity:
often fidgets with hands or feet or squirms in seat
often leaves (or greatly feels the need to leave) seat in classroom or in other situations in
which remaining seated is expected
feelings of restlessness
often has difficulty engaging in leisure activities that are more sedate
is often “on the go” or often acts as if “driven by a motor”
often talks excessively
Impulsivity
often blurts out answers before questions have been completed
often has difficulty awaiting turn
often interrupts or intrudes on others
6. State the student’s functional limitations based on the ADHD diagnosis, specifically in a
classroom or educational setting.
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7. State specifically recommendations regarding academic accommodations for this student and a
rationale as to why these accommodations/services are warranted based upon the student’s
functional limitations. Indicate why the accommodations are necessary (e.g. if a note taker is
suggested, state the reasons for this request related to the student’s diagnosis)
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8. 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.