Fillable Hearing Impairments And Deafness Documentation Form (Jacksonville University)

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Hearing Impairments And Deafness Documentation Form (Jacksonville University)

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JACKSONVILLE UNIVERSITY
Disability Support Services
2800 University Blvd. N.
Jacksonville, FL 32211
Phone: (904) 256-7067 -- Fax: (904) 256-7066
Documentation Guidelines
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 academic limitations.
The documentation must be within the last 3 years. However, the DSS reserves the
right to make modifications to this time frame.
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:
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Hearing Impairments & Deafness Documentation Guidelines
Students who are have a Hearing Impairment or Deaf should provide
documentation/medical diagnosis by an audiologist or other appropriate
physician.
The documentation must be in form of a medical report or physician’s
letter. Additionally an audiological report must be submitted.
Student Name:
Professional Signature:
Date:
Print Name, Title, Degree:
Professional License Number:
Contact Information:
Thank you for your prompt response to this request. Please return this information to:
Olga L. Florez, M.Ed., M.P.A
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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Hearing Impairments And Deafness Documentation Form (Jacksonville University)

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Completed 24 July 2020

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