Fillable Physical-Systemic-Documentation-Form Physical and Systemic Documentation Form2[1]

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Physical-Systemic-Documentation-Form Physical and Systemic Documentation Form2[1]

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PO Box 1129 • Eunice, LA 70535
Science Building Room 145
337-550-1204 • Fax 337-550-1268
www.lsue.edu/studentaffairs • ods@lsue.edu
JANUARY 2019
PHYSICAL AND SYSTEMIC (MEDICAL) DISABILITY
DOCUMENTATION REQUEST FORM
(TO BE COMPLETED BY QUALIFIED PROFESSIONAL)
When completing this form, please PRINT or TYPE and COMPLETE ALL FIELDS.
Incomplete forms will not be accepted.
**** If you have a formal evaluation, please attach the documentation.****
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, University Policy requires that a Qualified Professional provide current and comprehensive
documentation of the disability. A qualified professional includes a licensed psychiatrist, psychologist, medical doctor,
or other qualified medical or mental health professional who is not a family member of the student. IN ORDER TO BE
CONSIDERED CURRENT, THE QUALIFIED PROFESSIONAL’S EVALUATION MUST BE WITHIN THREE (3) YEARS PRIOR TO
THE DATE OF THE MOST RECENT REQUEST FOR DISABILITY ACCOMMODATIONS.
Student’s Name: _____________________________________ LSUE ID Number: ____________________
Date of Birth: ________________________________________________________________________________
Mailing Address __________________________________ City & Zip Code __________________
Phone Number: ______________________________________
1. Diagnosis (as diagnosed by the DSM-5) ___________________________________________________________
2. Date of Diagnosis: ______________________ Date of Last Contact with Student: _______________________
3. For the purpose of determining academic adjustments, describe the severity and longevity of the substantial
limitations due to a learning disability.
Physical and Systemic Disability | Page 2
JANUARY 2019
4. Describe the student’s functional limitations in an educational setting (i.e., current and/or anticipated problems
associated with the condition):
5. List current medication, along with any current side effects that may impact academic performance:
6. Please indicate the RECOMMENDATIONS you have regarding reasonable and appropriate auxiliary aids or
services, academic adjustments or other accommodations to ensure equity for the student’s academic success
based on the functional limitations indicated above.
Please check all that apply: ___ Extended Time (1.5X) ___ Distraction Reduced Environment
___ Alternative Test Format ___ Consideration for Absences ___ No Scantron
___ Books on Tape ___ Enlarged Text (font size ___) ___ Reader ___ Scribe
___ Other _____________________________________________________________________________
Qualified Professional’s Signature: _____________________________________________________________
Printed Name & Title: _______________________________________________________________________
Daytime Telephone Number: _________________________________________________________________
Address ________________________________________________ City & Zip __________________________
Date: _____________________________________________________________________________________
Submit this form and all necessary documentation via scan/email, fax, mail, or in person to:
Office of Disability Services
Louisiana State University Eunice
PO BOX 1129 • Eunice, LA 70535
Science Building Room 145
Phone: 337-550-1204 • Fax: 337-550-1268
Email: ods@lsue.edu
Physical and Systemic Disability | Page 3
JANUARY 2019
PO Box 1129 • Eunice, LA 70535
Science Building Room 145
337-550-1204 • Fax 337-550-1268
www.lsue.edu/studentaffairs • ods@lsue.edu
REQUEST FOR ACCOMMODATIONS
(TO BE COMPLETED BY STUDENT)
Student’s Name: _____________________________________ LSUE ID Number: _________________________
Date of Birth: _________________________________________________________________________________
Mailing Address ________________________________________________________________________________
City & Zip Code __________________________________________
Phone Number: _______________________________________________________________________________
I am requesting accommodations because I have been diagnosed with one or more of the following disabilities
that substantially limit and impair my ability to perform in an academic environment (Check all that apply):
___ Attention Deficit/Hyperactivity Disorder ___ Learning Disability
___ Psychological Disability ___ Deaf & Hard of Hearing
___ Physical or Systemic (Medical) Disability (specify): _________________________________________
In the space below, list and explain the reason for each of the accommodations you are requesting. What
accommodations, if any, have you received in the past? (i.e. during high school etc.) Please be as specific as possible.
Signature of Student: _______________________________________ Date: ______________________________
NOTE: The Office of Disability Services does not provide copies of any documentation. ODS
strongly recommend maintaining copies of any submitted documentation for your personal records.
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Physical-Systemic-Documentation-Form Physical and Systemic Documentation Form21

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Completed 2 July 2020

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