Fillable Doc. Of Disability-1-03 - Doc. of Disability-1-03

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Doc. Of Disability-1-03 - Doc. of Disability-1-03

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___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Office of Disability Services
DOCUMENTATION OF DISABILITY
Name (Print)_____________________________S.S.#.________________Phone__________________
Social security number is needed for registration verification and university employment only.
Address_____________________________________________City/State/Zip_____________________
By signing this form I grant permission for information concerning my disability to be released to
Wichita State University, Office of Disability Services. All documentation of disability information is
treated as confidential material.
Signature_____________________________________________ Date__________________
FOR PROFESSIONAL QUALIFIED TO MAKE DIAGNOSIS: The above student has requested that
you complete the following information or provide a written report that addresses all the areas listed to
verify their disability. To ensure the provision of reasonable and appropriate services for students with
disabilities, students needing services are required to provide current and comprehensive documentation
of their disability. Any information you can provide that offers recommendations for necessary and
appropriate auxiliary aids or service, academic adjustment, or other accommodation is needed.
Diagnosis____________________________________________________________________________
___________________________________________________
Date of Diagnosis
__________________
Duration of disability: PERMANENT______ TEMPORARY______ How Long__________
Activity limitations (check all that apply): Attention___ Hearing___ Reading___ Vision ___
Walking___ Writing___ Other______________________ Extent of Limitations:_________________
Suggestions of possible accommodations, auxiliary aids:______________________________________
Professional’s Name (Print) __________________________________Title______________________
Address__________________________________________ Daytime Phone(____)________________
Signature__________________________________________ Date____________________________
Please use additional pages to document all of the person’s disabilities in the same manner as above. It
is important we have all the person’s disabilities documented so we can provide the appropriate services.
Return the completed form to: Wichita State University
Office of Disability Services
1845 N. Fairmount
Wichita, KS 67260-0132
Wichita State University, Wichita, Kansas 67260-0132 Voice/TDD (316) 978-3309 Fax (316) 978-3114
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Doc. Of Disability-1-03 - Doc. of Disability-1-03

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Completed 11 March 2020

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