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Gratz College
Gratz College
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Instructions for Completion of the Student Accessibility Services Verification Form

Dear Healthcare Provider:

Your patient/client has requested academic accommodations from Accessibility Services at Gratz College.  We provide reasonable accommodations for students with disabilities and temporary medical conditions in accordance with the Americans with Disabilities Act of 1990 (ADA), Americans with Disabilities Act Amendments Act of 2008 (ADAAA), Section 504 of the Rehabilitation Act of 1973, as well as other applicable state and federal laws. Individuals requesting accommodations must disclose the nature of their impairment and provide documentation that verifies their current level of functioning. 

You have been asked to complete the Student Accessibility Services Verification Form ,which can be found online here, as documentation for your patient/client. To support Gratz College’s effort to provide appropriate access to accommodations and services for this student, we ask that you please complete all appropriate sections of this form.

Please take note of the following as you complete this form: 

  1. The person completing this form must be a healthcare provider who is either (1) qualified to assess and diagnose the student’s condition, and/or (2) is a part of the student’s treatment plan for a previously diagnosed condition (3) and is not a family member.  These professionals are generally trained, certified, or licensed to diagnose and/or treat medical conditions. Examples include psychiatrist, psychologist, therapist, social worker, medical doctor, optometrist, speech-language pathologist.

  2. Complete all parts of this form as thoroughly as possible. Inadequate information, illegible handwriting, or missing fields may delay the eligibility review process by necessitating follow up contact for clarification.  We recommend typing answers directly on this form, if possible, to avoid delays in processing. 

  3. Attach any other documentation or information you think would be relevant in determining the student’s academic accommodations.

  4. Attach the following completed verification form, or a separate letter on letterhead, providing information which confirms the diagnosis, severity, and recommended accommodations and includes the address, telephone number, name, title, and credentials of the evaluator. 

  5. The information you provide will be kept in the student’s file at Accessibility Services where it will be held securely and confidentially. This form may be released to the student if requested. 

  6. Specific types of disability documentation:

  • For students with diagnosed learning disabilities, the assessment or evaluation should be current, as within a time frame of 16 years of age or older to determine current impact. (LD assessments completed at age 16 or older use adult measures when determining impact which are considered unchanging). The assessment should use adult measures and include full results including a diagnostic interview, assessment of both aptitude and achievement and result in a diagnosis. 
  • For students with ADHD, psychological disorders, and/or chronic health conditions, documentation should include a clearly stated diagnosis, a description of functional limitations, be current within one year, include a list of any test instruments used in making a diagnosis, and a recommendation of specific accommodations. 
  • For students with blindness or visual impairments, documentation should include a clear diagnosis, severity of the condition, cause of visual impairment, date of onset, visual field and acuity, the functional impact of the impairment as related to learning in a higher education setting and lists any auxiliary aids and assistive technology that is needed to circumvent stated functional limitations. 
  • For students with mobility and/or a physical disability, if the disability is a permanent condition, documentation of any age is considered.  If the disability is based on a temporary condition, the documentation should be no older than one year. 
  • For students who are Deaf or are hard-of-hearing, documentation will include a clinical diagnosis from an audiologist, speech and hearing specialist or other qualified medical professional. In addition, documentation for students who are hard-of-hearing will include a current audiogram, a summary of assessment and evaluation instruments used in making the diagnosis, a statement of functional impact and specific need for accommodation, use of assistive listening devices, interpreters, or captioning. 


Once completed, please return this form back to the student so that he/she/they may deliver documentation to Accessibility Services. If you have questions regarding this form, please visit Accessibility Services online at, or contact me using the email address below. 


Thank you for your assistance. 


Signature of Naomi Housman

Naomi Housman, ADA Coordinator