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LEARNER DISABILITY INFORMATION / VERIFICATION FORM This form must be completed by the diagnosing professional only. Any form completed by the learner will not be accepted.
(Learner Name)
/ / ... is attending California Southern University beginning and is seeking a disability accommodation. Please provide the following information, along with appropriate documentation, describing your diagnosis and recommended accommodations for the above-named learner. Supporting documentation must be on letterhead, typed, signed, and dated by you, the diagnosing professional. Please write LEGIBLY. SECTION A – Diagnosis & Limitations 1. Please select one:
Temporary Disability (beginning
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and expected to last until
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)
Permanent Disability 2. Diagnosis(es): Primary Disability: Secondary Disability(ies):
3. Assessment(s) used in evaluating and diagnosing this disability(ies). Please include a clinical summary, laboratory and other test results, and test scores, including standard scores and/or percentiles for all normed measures. This information can be provided in separate documentation that is typed on letterhead, signed, and dated by you, the diagnosing professional.
4. Presenting limitations resulting from the above diagnosis(es) as they pertain to the educational environment:
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SECTION B – Accommodation Recommendations 1. Please recount any prior successful (or unsuccessful) accommodation(s) or auxiliary aids used, including any information about specific conditions under which the accommodations were used:
2. Please provide your recommendations for academic accommodations. Please explain why these accommodations are needed and how the limitations of the specific disability are accommodated. Please also provide the estimated length of time these accommodation services will be needed. Please Note: California Southern University is an online institution; all courses are presented online and are accessed by the learner through their web browser.
SECTION C – Supporting Information Acceptable supporting information includes: a) appropriate developmental, medical, psycho-social, employment, and family history; b) laboratory or other clinical test results; c) test scores, evaluation(s), determining test(s) along with the date of said testing; and d) clinical summary which includes the following: 1. Demonstration of ruled-out alternative explanations for academic problems;
2. Indication of how patterns and trends in the individual’s cognitive ability, academic achievement, and information processing reflect the presence of a specific learning disability; and 3. Indication of the substantial limitation to learning or other major life activity presented by the disability and the degree to which it impacts the individual in the learning context for which accommodations are being requested.
This information must be provided in separate documentation typed on letterhead, dated, and signed by you, the diagnosing professional. Total number of additional pages attached:
www.calsouthern.edu | 600 Anton Blvd Suite 1100 Costa Mesa, CA 92626 © 2022 California Southern University | Rev. 09.2019
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Thank you in advance for your prompt attention to this request. Please sign and return the information to the address below. Diagnosing Professional Printed Name (Title, Licenses, Credentials)
Diagnosing Professional Signature
Date
PLEASE RETURN TO: California Southern University Office of Disability Services California Southern University Attention: Disability Services 600 Anton Blvd Suite 1100 Costa Mesa, CA 92626 Tel: 714.882.7872 / 800.477.2254 ext. 4272 Email: disabilityservices@calsouthern.edu
www.calsouthern.edu | 600 Anton Blvd Suite 1100 Costa Mesa, CA 92626 © 2022 California Southern University | Rev. 09.2019