Blinn College District- Office of Disability Services
Documentation Verification
Student Name:
Blinn ID # or DOB:
Student Phone #:
Diagnosis:
Please provide specific and current functional limitations and the level of severity for this individual in an educational setting.
| Major Life Activity- Learning | No Impact | Mild Impact | Moderate Impact | Severe Impact | Unknown |
|---|---|---|---|---|---|
| Sustaining focus | |||||
| Attention/Concentration | |||||
| Retaining new information (memory) | |||||
| Understanding and following directions | |||||
| Organizing information, tasks, and materials | |||||
| Managing internal/external distractions | |||||
| Managing external distractions | |||||
| Learning Disability (504 Plan and/or ARD) | |||||
| Submitting assignments in timely manner | |||||
| Managing stress | |||||
| Managing paranoid ideations that may impact learning | |||||
| Containing emotions and behaviors | |||||
| Interacting with small groups | |||||
| Interacting with large groups | |||||
| Hearing Impairment | |||||
| Vision Impairment | |||||
| Sitting/standing/walking | |||||
| Writing (scribe)/ reading (reader) |
Please list any additional functional limitations for this student in a post-secondary educational setting:
Professional’s Name (print)
Signature
Date
Professional’s Title (print)
License Number
Address
Phone Number