Fillable Disability Support Services Guidelines and Release Form (Jacksonville University)

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Disability Support Services Guidelines and Release Form (Jacksonville University)

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The Disability Support Services Guidelines and Release Form (Jacksonville University) form is 4 pages long and contains:

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  • 65 check-boxes
  • 25 other fields

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File type: PDF

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1 | Page
Disability Support Services
2800 University Blvd. N.
Jacksonville, FL 32211
Phone: (904) 256-7067 -- Fax: (904) 256-7066
Guidelines and Release Form
Welcome to the office of Disability Support Services (DSS) at Jacksonville University (JU). To be
eligible for services at the DSS, a student must satisfy the definition of a disability as established by
the Americans with Disabilities Act of 1973. Section 504 defines a disability as a condition
which substantially limits one or more major life activities such as learning, walking,
seeing, hearing, breathing, caring for oneself, and working. To be eligible for
accommodations, a student must provide appropriate documentation of each disability that
demonstrates an accompanying substantial limitation to one or more major life activities.
The following guidelines are provided in the interest of assuring that professionals’ statement is
appropriate to document eligibility for support services. The student with a disability must provide
the office of DSS appropriate written documentation from a licensed professional in the field
concerning the specific diagnosis and expected limitations.
The documentation must be within the last 3 years. However, the DSS reserves the right
to make modifications to this time frame and due to the nature of the condition annual
documentation renewal may be needed.
I, __________________, hereby authorize the following information as well as any other
pertinent documentation to be forwarded to the office of Disability Support Services at Jacksonville
University for the purpose of determining my eligibility for academic accommodations.
Student’s Signature: Date:
Student Id#:
2 | Page
Documentation Guidelines for Housing Accommodations
1. Diagnosis/Impairment:
2. Diagnostic Codes (if applicable):
3. Date of Diagnosis:
4. Duration of disability/impairment:
____ Permanent: Level of severity: Minor ___ Moderate ___ Severe ___ Extreme ___
____ Temporary: Expected date of recovery: _____ Month/Year: ___
5. Describe how this medical condition may result in specific functional limitations and effects on
their academic life.
6. If the individual is currently undergoing treatment or taking medication, please describe how it
may affect his/her academic performance.
Important: In order to avoid room for misinterpretation of the following documentation, we request for it to be typed and not handwritten.
3 | Page
7. Are there any situations or environmental conditions that might lead to an exacerbation of the
condition?
8. Please check below the major college life activities and academic functions listed below that are
affected by the disability/impairment in a college setting, indicating the level of limitation.
Life Activity
Negligible
Moderate
Substantial
Walking
Breathing
Seeing
Hearing
Speaking
Sitting
Standing
Eating
Sleeping
Performing Manual Tasks
Learning
Thinking
Concentrating
Memory
Reading
Writing
Attending Class
Meeting Deadlines
Interacting with Others
Other:
9. Please indicate your recommendations regarding housing accommodations and explain
the need for these accommodations based on the diagnosed condition.
4 | Page
10. Please indicate how did you determine these recommendations? Check all that apply:
Student’s or parent request for the accommodation
Clinical assessment to determine the need for an accommodation
Mutual agreement determined through discussion between the clinician and student
Meets the definition of a disability* as defined by the American's with Disabilities Act &
Section 504 of the Rehabilitation Act of 1973. *Impairment that substantially limits a
major life activity.
Other : ____________________________________________________
Student’s Name:
Professional Signature:
Date:
Print Name, Title, Degree:
Professional License Number:
Phone:
Thank you for your prompt response to this request. Please return this information to:
Olga L. Florez, M.Ed., MPA
Director, Disability Support Services
Davis Student Commons, 3
rd
floor
Division of Student Affairs
2800 University Blvd. N.
Jacksonville, FL 32211
Email: oflorez@ju.edu
Phone: (904) 256-7067 -- Fax: (904) 256-7066
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Disability Support Services Guidelines and Release Form (Jacksonville University)

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Completed 21 August 2020

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