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Request for Documentation of a Disability
Disability Accommodations & Support Services
Arroyo Hall 210
Telephone 805-437-3331 Fax 805-437-8529 Email: accommodations@csuci.edu
The student named below has requested accommodations through Disability Accommodations & Support
Services (DASS) at Cal State Channel Islands. In order to provide reasonable accommodations, we require
documentation of the specific functional limitations that result from the individual’s disability and/or
medication side effects. General statements about the disability or medication do not help determine appropriate
accommodations. The purpose of the functional limitations is to indicate how a specific disability or
medication side effects substantially interferes with a major life activity, such as working or learning.
Information on this form will be used in confidence for the educational benefit of the student.
This information will be released to other parties only with the express written request of the student.
Please complete this form, or ON YOUR OFFICE’S OFFICIAL LETTERHEAD, please respond in
detail to each question and include your name, license number, phone, fax, address, signature, and date.
Thank you for your assistance. If you have further questions, please contact DASS at 310-437-3331 or
accommodations@csuci.edu.
First Name Middle Initial Last Name Date of Birth
1) DSM-5 and/or ICD-10 Diagnosis(es)
Diagnosis Specification Code Date of Diagnosis
Diagnosis Specification Code Date of Diagnosis
Diagnosis Specification Code Date of Diagnosis
Details:
2) What historical data was taken into account in making the diagnosis?
3) What were the assessment or evaluation procedures used to make this diagnosis?
