OFFICE OF DISABILITIES SUPPORT SERVICES
240 Academy Street
Alison Hall, Suite 130
Newark, Delaware 19716
(302) 831-4643
DSSoffice@udel.edu
Documentation of a Medical or Physical Disability
The student named below has applied for services from the Office of Disability
Support Services
In order for DSS to establish whether this student has a
disability and to determine his/her eligibility for services, we will need your
assessment and diagnosis of the student. A disability is defined as a physical or
mental impairment that limits one or more major life activities such as those
delineated below. You can fax or mail the form to us at the address listed on this
form. If you prefer, you can answer these questions in a signed and dated letter
on your professional letterhead.
All contact information and documentation received is kept in a separate, private file
within the Office of Disability Support Services. No information concerning inquiries
about accommodations or the documentation will be released/discussed without
written consent from the individual requesting accommodation/s. This information is
released/discussed on a need-to-know basis and is subject to FERPA.
Documentation is used to evaluate requests for accommodations or auxiliary aids.
The evaluation process includes a review of the documentation and how a request
for accommodations interfaces with the fundamental goals and essential standards
of the program, course, and service or benefit in question.
Student’s Name:_______________________________________________
Date: ____________________
1. What is the diagnosis/impairment?
2. What is the date of diagnosis?
3. Is the patient/student currently under your care?
4. When did you last see the patient/student?
5. Major Life Activities Assessment: Please check which of the major life
activities listed below are affected because of the impairment. Please
indicate level of limitation.
Life Activity
Talking
Hearing
Breathing
Standing
Working
Reaching
Negligible
Moderate
Substantial
Don’t know
Lifting
Sitting
Walking
Seeing
Writing
Performing Manual
Tasks
Caring for oneself
Sleeping
Learning
Reading
Thinking
Concentrating
Memorizing
Interacting with
Others
Other
6. What are the specific functional limitations resulting from the impairment’s
impact on the major life activities identified above?
7. Medications, effects, and possible side-effects:
8. If the student is currently undergoing treatment, please describe the
treatment and how treatment may affect the student in a post-secondary
setting.
9. Are the functional limitations permanent? If not, what is the expected
timeline for resolution?
Certifying Medical Professional:
Signature of Medical Professional
Printed Name and Title
Address
City, State, Zip code
Date
License #
Telephone #
Fax #