Disability Assessment Form Template
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Disability Assessment Form

Ensure all sections are filled out to enable a comprehensive assessment.

I. Medical Provider Information

Name

    Title

      Email

        Phone number

          II. Student Information

          Name

            Date of Birth

              Email

                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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