The following form may be filled out by a medical or mental health professional as a way to obtain the appropriate documentation of disability:

Examples of Helpful Documentation or Information

Self-reporting the impact or barriers experienced due to disability is a vital part of the accommodation request process and plan. The list below are examples of documentation to support or further inform about the student’s accommodation needs.

  • Educational records, such as the individualized education program (IEP), a 504 Plan, etc.
  • Neuropsychological or educational evaluation
  • Medical records
  • Statement or report from a health, mental health, or other service provider
  • Audiology report
  • Vision assessment

Information for Health, Mental Health or Other Service Providers

A statement or summary that includes any of the following information will assist us in determining an accommodation plan.

  • The current disability and the history of diagnosis (include relevant information about how the diagnosis was determined and date of onset or date of diagnosis)
  • Anticipated prognosis (if applicable)
  • Specific symptoms, including frequency and severity
  • The current treatment plan (if relevant to accommodation planning)
  • The extent of impact of the disability on major life activities (such as communicating, reading, writing, learning, working, walking, eating, breathing, etc.)
  • Any recommendations or strategies that would reduce the impact of the disability (including any relevant history of accommodations used in the past).

Along with the statement, the certifying professional must include:

  • Name and Title
  • Address
  • Daytime Phone Number
  • Fax Number
  • Type of specialty or license
  • License # and State where the license was issued
  • Signature and Date of Report