College of the Redwoods, Mendocino
DSPS Disability Verification
Disabled Student Programs and Services

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Date of Request: ___________________

The student named below may be eligible for special services at this college. In order to provide services, a verification of a qualifying condition must be on file with our office. (“Disabled Person” means any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. “Major life activities” mean functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.

Name:____________________________ *SSN/ID #:__________________ DOB:____________

Address:__________________________ City/State/Zip:_______________ Phone:____________

1. Diagnosis (Medical or DSM code and severity as applicable): _____________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. Please describe how this condition substantially limits major life activities.____________________
__________________________________________________________________________________
__________________________________________________________________________________
3. Condition is [ ] stable. [ ] prone to exacerbations.
4. Duration is [ ] permanent/chronic.
[ ] temporary (estimated duration _________________).

I understand that the information provided by the verifying professional will become part of the student record, and may be released to the student upon their written request.

Physician’s Signature _________________________________________ Date __________________
Print name/Title _____________________________________________

Please complete and return to:
Attention: Disabled Program Specialist
Disabled Student Programs and Services
College of the Redwoods, Mendocino Coast
1211 Del Mar Drive
Fort Bragg, CA 95437

*The Community College District uses the information requested on this form for the purpose of determining a student’s eligibility to receive authorized special services provided by the Disabled Students Programs and Services (DSP&S) Program. Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the Chancellor’s Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232 (g)). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. § 552a, note), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000 et seq.
Administrative Code, Title V, identifies the following disabilities for funding purposes:

I. Physical Disability means a visual, mobility, orthopedic or other health impairment.
a. Visual impairment means total or partial loss of sight.
b. Mobility and orthopedic impairment means a serious limitation in locomotion or motions functions which indicate a need for special services or special classes.
c. Other health impairment means a serious dysfunction of a body part or system which necessitates the use of one or more of the supportive services or programs.

II. Communication Disability is an impairment in the process of speech, language or hearing.
a. Hearing impairment means a total or partial loss of hearing function which impedes the communication process essential to language, education, social and/or cultural interactions.
b. Speech and language impairment means one or more speech – language disorder of voice, articulation, rhythm and/or the receptive and expressive processes of language.

III. Learning Disability is a persistent condition of presumed neurological dysfunction which may exist with other disabling conditions. This dysfunction continues despite instruction in standard classroom situations. Learning disabled adults, heterogeneous group, have:
a. Average to above average intellectual ability;
b. Severe processing deficits;
c. Severe aptitude-achievement discrepancy(ies);
d. Measured appropriate adaptive behavior in school or job setting;
e. Measured appropriate adaptive behavior in an instruction or employment setting.

IV. Acquired Brain Injury means a deficit in brain functioning which is nondegenerative or progressive and is medically verifiable, resulting in a total or partial loss of one or more of the following: cognitive, communication, motor, psycho-social or sensory perceptual abilities.

V. Developmentally Delayed Learner is a student who exhibits:
a. Below average intellectual functioning;
b. Impaired social functioning;
c. Potential or measurable achievement in a school or job setting;
d. Measured appropriate adaptive behavior in a school or job setting.

VI. Psychological Disability means a persistent psychological or psychiatric disorder, emotional or mental illness resulting in impairment of education or vocational functioning which requires disability-related support services or instruction pursuant Sections 56026 and 56028.
1. Verification by a licensed psychologist or psychiatrist that the student has a psychological disability according to the American psychiatric association diagnostic and Statistical Manual, Third Edition-Revised (DSM IV), that is coded on Axis I or II, and reflects a psychiatric or psychological condition that interferes with a major life activity, with the following exceptions:
a. Vcode (DSM IV): Conditions not attributable to a mental disorder that are a focus of attention or treatment of; or
b. All other conditions identified as exception in the Americans with Disabilities Act (28 CFR 35.104) Section 511 (b); Certain Conditions under this Act, the term “disability” shall not include:
1. transvestitism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders.
2. Compulsive gambling, kleptomania, or pyromania; or
3. Psychoactive substance use disorders resulting from current illegal use of drugs

2. The functional limitations(s) resulting from the psychological disability and how the student’s educational performance is impeded.

VII. Multiple Disabilities are defined as two or more functional impairments as described above.