Fillable Medical Or Physical Conditions Documentation Form (Jacksonville University)

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Medical Or Physical Conditions Documentation Form (Jacksonville University)

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The Medical Or Physical Conditions Documentation Form (Jacksonville University) form is 4 pages long and contains:

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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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Documentation Guidelines for Medical or Physical Conditions
1. Diagnosis/Impairment:
2. Diagnostic Codes (if applicable):
3. Date of Diagnosis:
4. Duration of disability/impairment:
____ Permanent
____ Temporary: Expected date of recovery: _______ Month/Year: _____
5. Describe how this medical condition may result in specific functional limitations in an
academic setting (e.g.., problems sitting for long periods of time, unable to type for
more than 10 minutes, or unable to walk more than 50 feet without fatigue)?
6. If the individual is currently undergoing treatment or taking medication, please
describe how it may affect his/her academic performance.
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7. Are there any situations or environmental conditions that might lead to an
exacerbation of the condition?
8. Please check below the major college life activities and academic functions listed
below that are affected by the disability/impairment in a college setting, indicating the
level of limitation.
Life Activity
Negligible
Moderate
Substantial
Walking
Breathing
Seeing
Hearing
Speaking
Sitting
Standing
Eating
Sleeping
Performing Manual Tasks
Learning
Thinking
Concentrating
Memory
Reading
Writing
Attending Class
Meeting Deadlines
Interacting with Others
Other:
9. Please indicate your recommendations regarding academic accommodations
and accompanying justifications for the student (e.g., note-takers, extended time
for tests, etc.).
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Student Name:
Professional Signature:
Print Name, Title, Degree:
Professional License Number:
Phone:
*Tests of cognition, information processing and academic achievement, which may not have been part
of the diagnostic process itself, maybe needed by DSS to determine appropriate academic
accommodations and services for a student with mobility impairment or other impairment due to a
medical condition.
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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Medical Or Physical Conditions Documentation Form (Jacksonville University)

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Completed 24 July 2020

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