Vision/Hearing Disability Documentation Form
STUDENT NAME: ___________________________________________ STUDENT PHONE: ____________________
STUDENT EMAIL(S):______________________________________________________________________________
STUDENT MAILING ADDRESS: _____________________________________________________________________
STUDENT: Please have this form completed by a qualified professional and return it to the Disability and Learning
Resource Center (address on following page).
To ensure the provision of reasonable and appropriate services for students with sensory disabilities at The School of
the Art Institute of Chicago, a licensed professional (e.g. physician, psychologist) must provide current and
comprehensive documentation of the differential diagnosis of the student’s disability. The current ADA defines a
disability as a physical or mental impairment that substantially limits one or more major life activities, such as: manual
tasks, walking, seeing, hearing, speaking, breathing, learning, thinking, concentrating, or working.
Please complete the following form for ______________ ______who has requested disability-related services and
accommodations from our office. (Please print clearly or type.)
*Please include an audiology report for Deaf and Hard of Hearing (DHH) documentation.
1. Diagnosis: __________________________________________________________________________
2. Date of Diagnosis: ____________________________________________________________________
3. Date of your last contact with the student: ________________________________________________
4. What procedures were used to diagnose the disorder?
5. Please describe the current symptoms of this disorder.
6. What is the expected duration, stability, and/or progression of this disorder?
7. Please briefly describe the current treatment, including medications including any possible side effects of the
Revised 06/13
8. Please describe the current functional impact of this disorder/disability on the student’s daily activities and academic
performance so that we can determine the specific accommodations which may be necessary.
9. If the student is requesting accommodations in a residence hall, please discuss the limitations to a major life function
and suggested means of accommodating this limitation.
10. What accommodations (e.g. testing modifications, adjusted course load, wheelchair accessible room, etc.) would you
suggest to enhance this student’s chance for success?
Signature: ____________________________________________ Date: _________________________
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
License #: ____________________________________________________________________________
Address: _____________________________________________________________________________
Phone: ____________________________________________
Please return this form to:
Valerie St. Germain
Disability and Learning Resource Center
The School of the Art Institute of Chicago
116 S. Michigan Ave, 13
Chicago, IL 60603
(312) 499-4278
(312) 499-4290 (fax)
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