Disability Assessment Form
Disability Assessment Form
Ensure all sections are filled out to enable a comprehensive assessment.
I. Medical Provider Information
Name
Title
Phone number
II. Student Information
Name
Date of Birth
Phone number
III. Disability Information
Type of Disability
Select all that apply:
-
Vision Impairment
-
Medical Illness
-
Mobility Impairment
-
Learning Disability
-
Hearing Impairment
-
Neurological Disorder
-
Autism Spectrum Disorder
-
Speech Impairment
-
Chronic Pain/Injury
-
Mental Health
-
Nature of Disability
-
Primary
-
Secondary
-
Tertiary
Duration of Disability
-
Temporary
-
Permanent
-
Unknown
Description of Disability
IV. Disability-Related Barriers
Specify the impact of the disability on the following areas from 1 (No Impact) to 5 (Major Impact):
A. Sensory
Vision
Hearing
Speech
Sensitivity to Light
Sensitivity to Noise
Sensory Overload
B. Academic Tasks
Writing Tests/Exams
Taking Notes in Class
Reading Comprehension
Meeting Deadlines
Delivering Oral Presentations
Following Instructions/Directions
Using Technology for Learning
C. Cognitive Abilities
Information Processing Speed
Long-Term Memory
Short-Term Memory
Attention Span
Problem Solving
Critical Thinking
Organizational Skills
Decision-Making
D. Physical Activity
Walking
Reaching for Objects
Carrying Things
Sitting for Long Periods
Climbing Stairs
Physical Endurance
Fine Motor Skills
E. Socio-Emotional
Managing Stress and Anxiety
Mood and Emotional Regulation
Social Interactions with Peers
Participation in Group Activities
Public Speaking
Coping with Change/Uncertainty
F. Additional Information
Diagnostic Methods
Please specify the methods used to diagnose disability and limitations:
Additional Limitations (if any)
Latest Clinical Assessment
Accommodation Recommendation
Please describe any specific accommodations you recommend for the student to ensure academic success:
V. Acknowledgment
I, the undersigned healthcare professional, hereby confirm that the information provided in this form is accurate and based on my professional evaluation of the student’s condition. My recommendations are made in the best interest of the student’s well-being and educational needs.
Name:
Date:
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