Office of Disability Services
Eastern
217-581-6583 (Voice/TTY)
217-581-7208 (Fax)
DOCUMENTATION OF ATTENTION DEFICIT DISORDER
To insure the provision of reasonable and appropriate accommodations, students requesting services must provide current documentation of the disability. This documentation should provide information regarding the onset, longevity and severity of symptoms, as well as the specifics describing how it has interfered with educational achievement. Therefore, individualized assessments of current cognitive processing and educational achievement are necessary. The following questionnaire should facilitate this information gathering. Appropriate services will be determined from the specific information provided.
Please return the completed form to the Assistant Director of Disability Services at the above address.
Student Name: _________________________________________________________________
Date: ________________________________________________________________________
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Diagnostic code (ICD or DSM-IV) _________________________________________________
Level of Severity: _______________________________________________________________
Date of Diagnosis: ______________________________________________________________
Date of Last Visit: ______________________________________________________________
Please check off the appropriate diagnostic criteria for AD/HD
A. Either (1) or (2)
1. Inattention
˙ a. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
˙ b. often has difficulty sustaining attention in tasks or play activities
˙ c. often does not seem to listen when spoken to directly
˙ d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
˙ e. often has difficulty organizing tasks and activities
˙ f. often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
˙ g. often loses things necessary for tasks or activities
˙ h. is often easily distracted by extraneous stimuli
˙ i. is often forgetful in daily activities
Please complete the reverse side of this form.
2. Hyperactivity-Impulsivity
˙ a. often fidgets with hands or feet or squirms in seat
˙ b. often leaves seat in classroom or in other situations in which remaining seated is expected
˙ c. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
˙ d. is often “on the go” or acts as if “driven by a motor”
˙ e. often talks excessively
˙ f. often blurts out answers before questions have been completed
˙ g. often has difficulty awaiting turn
˙ h. often interrupts or intrudes on others
˙ B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before the age of seven years.
˙ C. Some impairment from the symptoms is present in two or more settings.
˙ D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
˙ E. The symptoms do not occur exclusively during the course of Pervasive Development Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder.
Was medication prescribed? ˙yes ˙no If yes, what? _______________________________
Amount and frequency of administration: ___________________________________________
Frequency of monitoring: ________________________________________________________
Response to medication: _________________________________________________________
How will refills be obtained? _____________________________________________________
Is there any indication that this student may have an additional diagnosis like depression, anxiety, etc.?
__________________________________________________________________
Have you recommended any type of therapy? ________________________________________
Please include and attach any information you have on learning
disability testing, intellectual functioning, and/or academic problems which
you feel we should know in order to help this student.
Thank you for your help in providing this information so that we may begin providing services as soon as possible. Please return this form to the address shown on the letterhead.
Certifying Licensed
Physician, Psychiatrist or Clinical Psychologist/License #___________
____________________________________ ____________________________________
Name Typed or Printed Signature
Address: ______________________________________________________________________
______________________________________________________________________________
Phone: ______________________________ Date: ______________________________