Minneapolis College is an equal opportunity educator and employer. This document is available in alternative formats to individuals with disabilities by
calling Accessibility Resource Center at 612-659-6730 or by emailing accessibility@minneapolis.edu.
Disability Documentation Form
We welcome all forms of relevant documentation or information when working with a student to determine an
appropriate accommodation plan. To determine eligibility for services and/or accommodations, current and
comprehensive documentation regarding a physical or mental condition and its impact on the student’s function is
required from a licensed medical professional qualified to diagnose and treat the condition(s). See documentation
guidelines on page three of this document.
Student Information
Last Name First Name StarID
Diagnosis Information
Date of Diagnosis Most Recent Assessment Date
The Diagnosis must clearly state a DSM-V Diagnosis and must verify interference with a major life activity. Please
select the major life activities affected by the diagnosis.
Caring for one’s self
Social Interactions
Managing Stress
Regular and timely attendance
Managing internal distractions
Managing external distractions
Performing Manual tasks
Interacting with others
Making and keeping appointments
Maintaining deadlines
Current Symptoms.
Current Treatment Strategies and Prognosis.
Summary of the functional limitations of the diagnosis and the impact of medication and/or treatment on educational
Suggested Accommodations
Health Providers can provide suggestions for reasonable accommodations appropriate at the post-secondary level of
education. Such accommodations should be supported by the assessment results and by the diagnosis. The
Accessibility Resource Center will evaluate recommendations on a case-by-case basis. Accommodations must be
reasonable and cannot fundamentally alter the basic nature or essential elements of an institutions/s courses or
Provider’s Name Provider’s Title
Providers Credentials License# and State of Issue:
Business Phone Number Fax Number
Provider’s Signature Date of Report
Please fax this form to the Minneapolis College Accessibility Resource Center 612-659-6732
Disability Documentation Form | ARC 8/2020 Page 2
ARC Documentation Guidelines
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
Daytime Phone Number
Fax Number
Type of specialty or license
License # and State where the license was issued
Signature and Date of Report
Disability Documentation Form | ARC 8/2020 Page 3