STUDENT ACCESSIBILITY AND ACCOMMODATION
UNIVERSITY OF PUGET SOUND
Medical Documentation for Housing Issues Other than Single Room Request
STUDENT ACCESSIBILITY AND ACCOMMODATION
1500 N. Warner St. #1096, Tacoma, WA 98416-1096, T: 253.879.3395 or 3399, F: 253.879.3786
Student’s Name: _____________________________ Student DOB: ______________________
Student ID# _____________ Telephone ______________________________ Date ___________
Student Accessibility and Accommodation complies with federal and state disability laws that
prohibit discrimination and require that universities ensure equal access for qualified persons with
disabilities to educational programs, services and activities. Please complete the form below to
assist DS in determining appropriate and reasonable disability accommodations.
To be completed by the student’s treating professional
Complete Diagnosis: ________________________________
_______
Date of Diagnosis: ________________________________
Please describe the functional limitations:
_______________________________________________
_____
Date of last visit for this condition: ___________________
How often does this student experience the above
limitation(s)? Rarely Occasionally Frequently
Procedures/assessments used for diagnosis:
________________________________________________
________________________________________________
How will the above limitation(s) interfere with this student’s
ability to participate in student life?
______________________________________________
Severity: Mild Moderate Severe
_______________________________________________
Student is compliant with medical treatment for this
condition: Rarely Sometimes Often Unknown
Does this student take prescription medication for this
condition? Yes __ No __ If yes, which medications?
Please note any side effects:
______________________________________________
________________________________________________
Has this student been treated in an emergency room for this
within the last year? Yes ___ No ___
Has this student received in-patient treatment for this
condition within the last year? Yes ____ No ____
Describe any substantial equipment prescribed for this
student’s home or school environment. ________________
________________________________________________
________________________________________________
Describe your follow-up plan with your patient for whom
you have requested specialized campus residence housing:
_______________________________________________
________________________________________________
Recommended accommodation (must be clearly linked to
functional limitations): _____________________________
Treating Professional’s Signature: _________________
________________________________________________
Affix business card or apply business stamp within this box
Treating Professional’s Name: _____________________
_____________________________________________
Address: ______________________________________
_____________________________________________
License / Cert. #: _______________State: ___________
Phone: _________________ Fax: __________________
Email: saa@pugetsound.edu
Revised 07/15/2013