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Note: A health professional must fill
out this form and send it to Admissions/Disability Services,
Northeast Alabama Community College, P. O. Box 159, Rainsville,
AL 35986.
IMPAIRMENT AND DISABILITY ASSESSMENT
In order for Northeast Alabama Community College to
provide disability-related
services, we need to establish this student has a
disability. A disability is defined as an
impairment substantially limiting a major life
activity. This form is designed to help us make
that assessment. Please respond to the following
items:
Date:
_________________________________________________________________
Health professional's name:
______________________________________________
Phone:
________________________________________________________________
Clinic name and address:
________________________________________________
______________________________________________________________________
Health professional's signature:
__________________________________________
Student's name:
________________________________________________________
I. Impairment Assessment
A. What is the diagnosis/impairment?
___________________________________________________________________
B. When was the diagnosis originally made?
___________________________________________________________________
C. Is the patient/student currently under your
care?
___________________________________________________________________
D. When did you last see the patient/student?
___________________________________________________________________
E. Is the impairment temporary (<6 months) or
persistent?
___________________________________________________________________
II. Major Life Activities Assessment
Please check any of the major life activities listed
below that are affected as a result of the
impairment. Please indicate the level of limitation.
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1 = Negligible |
2 = Moderate |
3 =
Substantial |
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1 |
2 |
3 |
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Caring for oneself |
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Talking |
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Hearing |
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Breathing |
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Standing |
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Working |
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Reaching |
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Lifting |
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Sitting |
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Walking |
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Seeing |
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1 |
2 |
3 |
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Writing |
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Performing manual tasks |
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Sleeping |
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Learning |
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Reading |
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Thinking |
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Concentrating |
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Memorizing |
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Taking exams |
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Interacting with others |
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Other: |
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What are the functional limitations resulting
from the impairment's impact on major life
activities identified in # 2 above?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Based upon the major life activities affected by the
impairment, are there any accommodations
within the context of the community college
environment that you can recommend for this
student?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Source:
University of Wisconsin-Madison
and Athens State University |
