DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)5261200ext.8534
Fax(908)5263494
disabilityservices2@raritanval.edu
Chronic Medical Disability Documentation Form
Please complete this form with as much detail as possible, as a partially completed form or limited responses
may hinder the eligibility process. It is most important that you thoroughly explain any symptoms and indicate
their impact on functioning. If you wish to provide additional information, please attach it to these forms.
Thank you for your assistance.
To be completed by the licensed, treating healthcare professional only
Student’s name: ___________________________________________________________________________
Today's date: ________________________
What is the student’s diagnosis? _______________________________________________________________
How long has the student has this diagnosis/condition? _____________________________________________
Date of initial contact with student: _________________ Date student was last seen: __________________
Frequency of appointments ____________________________________________________
What is the severity of the condition? Mild Moderate Severe
What is the expected duration? Chronic (more than a year) Episodic Short-term (six months - one year)
Please explain severity and duration: ___________________________________________________________
Provide information regarding the student’s current symptoms and functional limitation that you feel are
relevant to the academic setting
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List the student’s current medication(s), including dosage, frequency, and adverse side effects (if applicable):
__________________________________________________________________________________________
__________________________________________________________________________________________
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)5261200ext.8534
Fax(908)5263494
disabilityservices2@raritanval.edu
Are there significant limitations to the student’s functioning directly related to the prescribed medications?
___ Yes ____ No If yes, explain: ____________________________________________________________
Please provide your specific recommendations (based upon your assessment, the student’s clinical and
academic history, and diagnosis) for reasonable accommodations that you believe will help equalize the
student’s ability to access the RVCC’s educational program along with rationale for each):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Additional information you believe would be helpful in determining the nature and severity of this student’s
disability, and any additional recommendations that may assist DS in determining appropriate accommodations:
__________________________________________________________________________________________
__________________________________________________________________________________________
Certifying Professional
____________________________________ ______________________________
Name and Title Area of Specialty
____________________________________ ______________________________
License Number State of Licensure
____________________________________ ______________________________
Address Phone Number
____________________________________ ______________________________
City, State, Zip Fax Number
____________________________________ ______________________________
Signature of Certifying Professional Date
Please return to:
Disability Services - Raritan Valley Community College
College Center C-124
Fax (908) 526-3494
disabilityservices2@raritanval.edu
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