Student Accessibility Services - VERIFICATION OF DISABILITY FORM FOR MEDICAL PROVIDERS

Your Information

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Name of Medical Professional:

Degree/Speciality:

Your phone number:

Your email address:

Email address must be of a valid format.

License # (indicate state):

Student Information

Name of student

Medical Information

Medical Diagnosis(es):(Required) This field is required.

Onset of Condition(s):(Required) This field is required.

Current Status of Condition(s) (e.g. Active, Progressing, Controlled, In Remission):(Required) This field is required.

How long is this condition(s) likely to exist (be as specific as possible: e.g., lifetime, one academic year; one semester; one month):(Required) This field is required.

What are the student’s current functional limitations (again, be as specific and detailed as possible): 1) ambulation; 2) upper extremity motor function; 3) hearing; 4) vision; 5) cognitive processes—concentration, rapidity of information processing, fatigability, others:(Required) This field is required.

What major life activities does the student’s condition impair?(Required) This field is required.

In comparison to the average person in the general population, please rate the severity of the student’s functional limitations noted above with the use of mitigating measures, such as medication and treatment:(Required)

Mild Moderate Substantial Severe

This field is required.

In comparison to the average person in the general population, please rate the severity of the student’s functional limitations noted above without the use of mitigating measures, such as medication and treatment:(Required)

Mild Moderate Substantial Severe

This field is required.

What exacerbates the specific disability(ies) this student has? (Again, be as specific and detailed as possible.)(Required) This field is required.

Please list any medications related to the condition(s) that the student is currently taking, including dosage and frequency, if pertinent. Please include both the positive as well as any negative effects of the medication:(Required) This field is required.

Please describe the impact that the student’s condition will have on his/her ability to attend or participate in classes:(Required) This field is required.

Please describe the impact this student’s condition has on his/her overall ability to learn, or on other cognitive abilities:(Required) This field is required.

Identify any accommodations you believe may be necessary in order for the student to participate in the University’s programs, activities and services:(Required) This field is required.

Please type your initials below. By doing so, you certify that you are the person listed as completing this form, and you verify that you are not related to the student by blood or marriage. You also confirm that all information you have provided is accurate.(Required) This field is required.

Supporting Documentation

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Your Information

Student Information

Medical Information

Supporting Documentation

Submission