Disability Summary Report Form
Student Name: Student Date of Birth:
The above-mentioned student has requested academic accommodations from the Office of Disability Services
(ODS) at Texas State University on the basis of disability. In order to determine whether the student qualifies
for services, we ask that you as the health care provider please provide the following information. Once
completed, please return the completed form to the Office of Disability Services.
1. Please identify all diagnoses for this student, provide the corresponding codes from either the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) or International Statistical Classification
of Diseases and Related Health Problems (ICD-10), and indicate the date of diagnosis.
Code and Diagnosis Name Date of Diagnosis
2. Date of first contact with student:
Month/Day/Year
3. Date of last contact with student:
Month/Day/Year
4. List any side effects related to treatment or medications:
OFFICE OF DISABILITY SERVICES
601 University Drive | LBJ Student Center 5-5.1 | San Marcos, Texas
78666-4616
phone: 512.245.3451| fax: 512.245.3452 |
WWW.ODS.TXSTATE.EDU
5. Describe the student’s current functional limitations and the impact they have on the student in the
educational environment.
6. Indicate the academic accommodations that you are recommending and why they are necessary.
Recommendations must be clearly linked to the functional limitations of the students condition(s).
7. If applicable, indicate the housing and/or dining accommodations that you are recommending and why they
are necessary. Recommendations must be clearly linked to the functional limitations of the students
condition(s).
8. If available, please attach copies of complete medical records, psychiatric records, and/or psychological
reports to this form.
Certifying Professional By signing below (print/type), you are confirming that you are the qualified
healthcare professional who is providing the information above.
Name: License #:
Address: Phone:
Signature:
Date:
Please fax the completed form to the Office of Disability Services at 512.245.3452. If you have any questions,
feel free to contact our office. Thank you.
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