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Disability Services
PHYSICAL AND SYSTEMIC (MEDICAL) DISABILITY
DOCUMENTATION REQUEST FORM
****This form must contain ALL of the REQUESTED INFORMATION and be TYPED or
PRINTED in order to apply for accommodations through Disability Services.****
Student’s Name: _______________________________________________________________________________
Date of Birth: _________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone Number: ________________________________________________________________________________
B# : ________________________________________________________________________________________
This student is requesting an auxiliary aid or service, academic adjustment, and/or other accommodations from
Disability Services. In order to consider this request, as well as to ensure the provision of reasonable and
appropriate auxiliary aids and services, College Policy requires that a Qualified Professional provide current and
comprehensive documentation. A qualified professional includes a medical doctor or other qualified healthcare
professional who is not a family member of the student. IN ORDER TO BE CONSIDERED CURRENT, THE
QUALIFIED PROFESSIONAL’S STATEMENT MUST BE WITHIN 3 YEARS PRIOR TO THE DATE OF THE
MOST RECENT REQUEST FROM DISABILITY SERVICES.
The documentation provided must include information that diagnoses a physical or systemic (medical) disability,
describes the functional limitations in an educational setting, indicates the severity and longevity of the physical or
systemic (medical) disability for the purpose of determining academic adjustment(s) or other accommodation(s), and
lists current medication along with any current side-effects which may impact academic performance.
If it is a visual disability the documentation must include the student’s visual acuity (best corrected), a description of
the effects of the visual problems, and a recommended font size for text when enlarged text is recommended as an
accommodation.
To facilitate the gathering of such critical information, please respond to the following and return to SOWELA,
Disability Services.
2. Diagnosis _________________________________________________________________________________
3. Date of Diagnosis: ___________________________ Date of Last Contact with Student:_______________
4. Provide a summary of the student’s educational, medical, and family history that relates to the physical or
systemic (medical) disability (difficulties must be related to the diagnosed disability and are not the result of
other conditions, cultural differences, or insufficient instruction):
5/2012 1
