Kankakee Community College
Office of Disability Services
Reasonable Accommodation Verification Form

Kankakee Community College (KCC) is required by Section 504 of the Rehabilitation Act and the Americans with Disabilities Act to provide reasonable accommodations, in the form of academic adjustments and auxiliary aids and services, for qualified students with documented disabilities. The purpose of reasonable accommodations is to provide equitable access to all aspects of the college's programs. The outline below has been developed to assist the student in working with the treatment or diagnosing healthcare professional (psychiatrist, psychologist, counselor, social worker, medical doctor, optometrist, speech-language pathologist, etc.) in obtaining specific information to evaluate eligibility for reasonable accommodations in the higher education setting.

KCC's Office of Disability Services (ODS) endeavors to provide reasonable accommodations for qualified students with documented disabilities. ODS does not modify essential elements of an instructional program or course or provide accommodations for students whose impairments do not substantially limit one or more major life activities. This form is designed to allow ODS to achieve these goals. The healthcare provider need not use this specific form, but all the information requested here is necessary to consider the request; the form is provided as a convenience.

Please take note of the following as you complete the form:

1. The person completing this form should be a qualified medical professional who is (1) qualified to assess and diagnose the student's condition, and/or (2) was a part of the student's treatment plan for a previously diagnosed condition.
2. Please complete all parts of this form legibly and as thoroughly as possible. Inadequate information, incomplete answers, and/or illegible handwriting will delay the eligibility review process by necessitating follow-up contact for clarification. This PDF provides fillable form fields to allow for typed answers. Typed answers are highly recommended.
3. The healthcare provider or student should attach any documents which provide additional related information. (e.g., psychoeducational assessment, neuropsychological test results, an Individualized Education Program (IEP), Multifactor Evaluation (MFE), Evaluation Team Report (ETR), a 504 plan, verification of accommodations provided by another college/university or third-party entity, etc.) If a comprehensive diagnostic report is available that provides the requested information, copies of the report can be submitted for documentation in place of this form. In addition to the requested information, please attach any other information that would be relevant to the student's need for accommodations.

For questions regarding this form, please contact
Office of Disability Services via email at
disabilityservices@kcc.edu

Reasonable Accommodation Verification Form Instructions

1. Preview: Use the "Download PDF for Printing" button below to review your document.
2. Verify: Check for accuracy. If needed, go back to the form to make edits.
3. Download & Print: Click the Download button () in the upper-right corner and then print the file.
4. Sign: Read the authorization, sign, and date the student signature line. This provides consent for your healthcare provider to share relevant information with the Office of Disability Services for the next 60 days.
5. Healthcare Provider: Deliver the signed document to your healthcare provider to complete the remaining sections.

Please return the completed form to:
Kankakee Community College, Office of Disability Services
100 College Dr. Kankakee IL 60901

Questions?
Reach us by phone: 815-802-8632