STANDARD DOCUMENTATION FORM
(to be completed by a qualified professional only)
Are you currently providing treatment for these diagnosis/diagnoses? ¨ Yes ¨ No
Do(es) the condition(s) listed above have a substantial limitation on a major life activity for this person? ¨ Yes ¨ No
Which of these major life activities is limited?
¨ Self Care
¨ Social Interactions
¨ Doing Manual Tasks
Speciﬁcally describe how the condition contributes to functional limitations in an academic setting for this person and to what
degree the person is limited.
What test(s), if any, were done to determine diagnosis and/or limitations?
If this person is taking any prescribed medications, please describe any functional impairment these medications may
What reasonable academic accommodations would you support on behalf of this person?
Name and Title of Qualiﬁed Professional
License # State
Evaluation report and/or documentation forms themselves do not automatically qualify student(s) for reasonable accommodations.
Counseling & Career Services oce will make ﬁnal decisions regarding accommodations and any other services they or
Midlands Technical College may provide.
PO Box 2408
Columbia, SC 29202
airport fax 803.822.3295
beltline fax 803.790.7515