Educational Support Center
Science Hall 150
Schnecksville, PA 18078
Ph: 610-799-1156
Fax: 610-799-1068
Request for Assistance
Documentation of Temporary Impairment
Please return this form completed by a licensed physician to address above.
STUDENT TO COMPLETE:
I authorize my physician to release the information requested, as part of my Request for Assistance due to a Temporary
Impairment. I understand that the information will be handled in a confidential manner and in compliance with HIPAA.
Patient Name: ID#:
Student Signature: Date:
PHYSICIAN TO COMPLETE:
Diagnosis:
Date of onset:
Dates under your care for this specific illness:
Date(s) of hospitalization, if applicable:
Treatment plan:
Effect(s) the condition has on the student’s ability to perform academically:
Assistance required:
PLEASE PRINT
Name of Physician: Phone:
Address:
Signature of Physician: Date:
Professional License ID #:
The College will not discriminate against any employee, applicant for employment, student, or applicant for admission on the basis of gender, gender identity, gender expression, sex, race, ethnicity, color, national origin,
religion, age, disability, veteran or military status, genetic information, family or marital status, sexual orientation, or any other protected class under applicable local, state, or federal law, including protections for those
opposing discrimination or participating in any grievance process on campus or within the Equal Employment Opportunity Commission or other human rights agencies. This policy applies to all terms and conditions of
employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Inquiries about this policy and procedure may be made internally to the
Director of Human Resources/Title IX/Equity Coordinator, Office of Human Resources, 4525 Education Park Drive, Schnecksville, PA 18078, 610-799-1107. PERM24A-t (AC)
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