|
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:
|
Health professional's name:
|
|
|
Health professional's signature:
|
|
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When was the diagnosis originally made?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.
|
|
1 = Negligible
|
2 = Moderate
|
3 = Substantial
|
|
Caring for oneself
|
|
|
|
|
Talking
|
|
|
|
|
Hearing
|
|
|
|
|
Breathing
|
|
|
|
|
Standing
|
|
|
|
|
Working
|
|
|
|
|
Reaching
|
|
|
|
|
Lifting
|
|
|
|
|
Sitting
|
|
|
|
|
Walking
|
|
|
|
|
Seeing
|
|
|
|
|
Writing
|
|
|
|
|
Performing manual tasks
|
|
|
|
|
Sleeping
|
|
|
|
|
Learning
|
|
|
|
|
Reading
|
|
|
|
|
Thinking
|
|
|
|
|
Concentrating
|
|
|
|
|
Memorizing
|
|
|
|
|
Taking exams
|
|
|
|
|
Interacting with others
|
|
|
|
|
Other:
|
|
|
|
|
Other:
|
|
|
|
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 |
