2/28/17
Medical/Psychological Documentation for Student Housing Accommodation Request
To be completed by the student:
Student Name_________________________________________________________________
Student ID Number: 70__________ E-mail _________________________________________
Cell Phone Number ( _____) _________ Date of Birth ______________________________
Current Address _______________________________________________________________
I am requesting:
☐ A single room ☐ Permission to live off campus ☐ Other_________________________________
To be completed by the medical/psychological professional:
The above person is a student at SUNY Plattsburgh who is requesting housing accommodations based on a
disability or diagnosed medical or psychological condition. Your assistance with our evaluation of the
student's request is greatly appreciated.
Please complete the following questionnaire.
Is the student currently under your care? ☐ Yes ☐ No
If yes, for how long has the student been under your care? ___________________
What was the date of the most recent contact you had with this student? ______________________________
The student named below is applying for a medical accommodation within our residence life program. In
order for us to establish whether this student qualifies for a medical accommodation, we need your
assessment and diagnosis of the student. This form should be used for medical singles and medical
releases or exemptions to live off campus. The completed form can be sent by fax, email, or regular mail.
All documentation received will be kept confidential, except in cases where we need to consult with other
offices on our campus (i.e. Accommodative Services, Counseling Center, Student Health Services, Dining
Services) or as required by law. This information is shared on a need-to- know basis and is subject to
FERPA. No information concerning inquiries about accommodations or the documentation will be
released without written consent from the individual requesting the medical accommodation.
