Disability Verification (Dv) Form - Fullerton College
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1CONFIDENTIAL
DISABILITY VERIFICATION (DV)
PLEASE RETURN OR FAX TO:
FULLERTON COLLEGE • DISABILITY SUPPORT SERVICES
321 E. Chapman Avenue • Fullerton, California 92832
Phone (714) 992-7099 • Fax (714) 992-9920
The student named below may be eligible for special services at this college. In order to provide services
we must have a verification of disability/diagnosis. The information you provide will be used for the sole
purpose of determining eligibility for and authorization of accommodations at Fullerton College.
____________________________________________________
__________________
Last Name
First Name
M.I.
Date of Birth
_________________________________________
____________________________
Phone Number
Student ID#
Please provide the following information IN FULL in order to help us determine reasonable educational
accommodations to support this student:
1. Diagnosis: ___________________________________________________________________________
If applicable, DSM IV Code and Severity: __________________________________________________
2. Duration of Condition
Permanent/Chronic
If temporary, give estimated duration__________________________________________________
3. Condition is:
Stable
Observable
Prone to exacerbations
Non-observable
4. Prescribed Medication(s), Dosage and Side effects: ____________________________________________
______________________________________________________________________________________
5. Functional limitations of condition and/or medication (e.g. the ways in which the diagnosis and/or side effects
of medications affect the student.) Please check:
Speaking
Hearing loss
Processing oral material
Limited ambulation
Taking class notes
Processing visual materials
Visual acuity
Providing written assignments
Easily distracted
Poor concentration
Slow processing of information
Other: ______________________________________________________________________________
______________________________________________________________________________________
6. Please list other special assistance needed: __________________________________________________
______________________________________________________________________________________
I understand that the information provided in this form will become part of the student record subject to the
Federal Family Education Rights and Privacy Act (FERPA) of 1974 and may be released to the student upon
written request.
Signature ______________________________________
______________________
_______________
Verifying Licensed Professional
Title/License #
Date
Name (printed) ___________________________________________________________________________
Address ________________________________________________________________________________
Phone _____________________________________
FAX __________________________________
Rev. January 2013
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