DISABILITY SERVICES
STANDARD DOCUMENTATION FORM
(to be completed by a qualified professional only)
Name: DOB:
First Last
Diagnosis/Diagnoses:
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?
¨ Walking
¨ Self Care
¨ Reading
¨ Vision
¨ Learning
¨ Writing
¨ Hearing
¨ Social Interactions
¨ Speaking
¨ Breathing
¨ Thinking
¨ Calculating
¨ Doing Manual Tasks
¨ Concentrating
¨ Working
¨ Other
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
likely cause.
What reasonable academic accommodations would you support on behalf of this person?
Signed Date
Name and Title of Qualified Professional
License # State
Name Title
Address
Phone Fax
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.
midlandstech.edu
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PO Box 2408
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Columbia, SC 29202
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airport fax 803.822.3295
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beltline fax 803.790.7515
SD-18-4899-08-18
