Fillable Disability Summary Report Form The above-mentioned student has (Texas State University)

Fill Online, Printable, Fillable, Blank Disability Summary Report Form The above-mentioned student has (Texas State University) Form

Use Fill to complete blank online TEXAS STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Disability Summary Report Form The above-mentioned student has (Texas State University)

On average this form takes 6 minutes to complete

The Disability Summary Report Form The above-mentioned student has (Texas State University) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Texas State University

BROWSE TEXAS STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 student’s 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 student’s
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.
2
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Disability Summary Report Form The above-mentioned student has (Texas State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document