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Letter for requesting physical disability documentation

Dear Doctor:
In order to receive appropriate academic and/or physical accommodations, the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 allow institutions to request supporting documentation of a disability. Without such written documentation, a student will be unable to receive appropriate academic accommodations that may be critical for his/her success. If you prefer to use this form rather than a narrative report, please indicate each of the criterion that are applicable to this student. The documentation for eligibility should be current, preferably within the last three years.

Student's name: ________________________________________________
Student's SS#:_____________________________________________

Medical Diagnosis: ______________________________________________
Present Symptoms: ______________________________________________
______________________________________________________________

1. Which of these major life activities is substantially limited by this student's disability (in the academic setting)?
   • caring for one's self
   • performing manual tasks
   • walking
   • seeing
   • hearing
   • speaking
   • breathing
   • learning
   • working
   • other:
   • none of the above (please explain):
2. Statement of severity and duration of the impairment:
3. Statement of permanent or long term impact of the impairment:
4. What treatment or medication is prescribed for this condition?
5. How does this condition and/or the effects of the medication limit the student's ability to learn and/or meet the demands of the academic program (please use additional pages if necessary)?
6. Effects of medication:
   a. drowsiness
   b. impaired motor skills
   c. decreased concentration
   d. other (please specify): ________________________________________________________
   e. not applicable
7. Based on the results of your evaluation, what accommodations would you suggest for academic adjustments?
   • extended time on exams
   • exams in a distraction free environment
   • use of note takers
   • alternative test format
   • tutorial service
   • priority enrollment
   • special seating arrangements
   • breaks during instruction
   • reduced course load
   • use of adaptive technology
     • voice activated software
     • word processor
     • screen reader
     • other (please specify):
   • other adjustments (please explain):
   • no adjustments needed (please explain):
8. Hearing impairments: Please include a current (no more than three years old) audiological report from a licensed audiologist.
9. Visual impairments: Please include a current (no more than three years old) eye examination from a licensed opthamologist.
10. Physical/health impairments: Please include a current history and physical report.

Signature: ___________________________________

Name: _____________________________________

Address: ___________________________________

Office phone: ________________________________

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