Documentation Release

In order for (student name) to receive services through the Alternative Media Access Center (AMAC), I, (service provider) verify documentation is on file at (institution or agency) supporting that (student name) demonstrates a functional limitation in the ability to access print materials. The documentation for (student name) follows the AHEAD Seven Essentials for Documentation and can be accessed as necessary at any time.

Verification

I, (service provider), verify the following essentials are included in this documentation:

1. The credentials of the evaluator(s)
2. A diagnostic statement identifying the disability
3. A description of the diagnostic methodology used
4. A description of the current functional limitations [requiring alternative media and/or assistive technologies to access print]
5. A description of the expected progression or stability of the disability
6. A description of the current and past accommodations, services and/or medications
7. Recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or items support services

Student Disability(ies)

Primary Print Disability:____________________________

Secondary Disability:______________________________

Instructions and Signatures

Please print and sign this form. Be sure to make a copy for your records. Fax or mail signed forms to:

The Alternative Media Access Center
512 Means Street, Suite 250
Atlanta, Georgia 30318
or
Fax to 404-894-8323.

DSP Signature	Print Name	Date

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Approved: yes / no

UGA RCLD/AMAC Documentation Liasion	Print Name	Date