Verification Form

SAS Verification Form

This form is to be filled out, in its entirety, by a qualified health professional who is currently treating the student. This professional must be unrelated to the student. Forms with insufficient detail will prompt a request for more information. For non-Dartmouth providers, this form must be accompanied by a short letter on letterhead signed by the professional.

For learning, attention, and autism spectrum diagnoses, a complete psychoeducational or neuropsychological evaluation is preferred in lieu of completing this form. SAS may also request copies of lab tests or other assessment measures.

Student Information
Provider Information
Summary of Current Care
Please be mindful that Dartmouth has a compressed, ten-week quarter system.
Historical/Assessment Information
Supplemental Accommodation Request Information
These may be included in your signed letter and must be accompanied by an explanation of their relevance to the student’s condition. Final determination of appropriate accommodations will be determined by SAS.