Fillable Documentation of Disability (Hawaii Community College)

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Documentation of Disability (Hawaii Community College)

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Documentation of Disability
Student Name: _______________________________________ Date of Birth: _____________________
Diagnosis/Condition: ___________________________________________________________________
Date of Diagnosis/Condition: _____________________________________________________________
Current Symptoms related to diagnosis/condition: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are the symptoms expected to last six months or longer? _______ YES _______ NO
If no, when do you foresee the symptoms to abate? __________________________________________
Substantial areas that impact daily functioning or education: ___________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Ongoing medical treatment needed: _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
200 W. Kawili St.
Hilo, Hawai’i 96720-4091
Telephone: (808) 934-2509
Fax: (808) 934-2501
www.hawaii.hawaii.edu
An Equal Opportunity/Affirmative Action Institution
Any feedback or suggestions on reasonable accommodations for this diagnosis/condition: ___________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional comments: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Professional’s Signature: _________________________________ Date: __________________________
Print Name: ___________________________________________________________________________
200 W. Kawili St.
Hilo, Hawai’i 96720-4091
Telephone: (808) 934-2509
Fax: (808) 934-2501
www.hawaii.hawaii.edu
An Equal Opportunity/Affirmative Action Institution
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Documentation of Disability (Hawaii Community College)

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Completed 7 September 2020

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