THE UNIVERSITY OF NORTH CAROLINA AT WILMINGTON
RELEASE of Information:
I, (STUDENT) ___________________________________, hereby authorize the release of the following information for
the purpose of determining my eligibility for academic accommodation, as based on the federal guidelines for the
definition of a disability. If you have any questions, please contact the Disability Resource Center, UNCW, 601 S.
College Rd. Wilmington, NC 28403-5942. Phone: 910-962-7555
FAX: 910-962-7556. E-mail:
TurnerM@uncw.edu
___________
Date
___________________________________________
Signature of Student
______________________
UNCW Student ID #
Peggy Turner, EdD.
7/24/12
Director – Disability Resource Center
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DIAGNOSIS: _______________________________________________________________________________
___________________________________________________________________________________________
How long has your patient retained this diagnosis? _________________________________ year(s).
What is the percentage of functioning (PIF) lost or seriously impaired (0 to 100%), and what percentage of time (PIT) is
your patient unable to perform the major activity(ies)?
ACTIVITY
PIF
PIT
1.
_________________________________________
____________%
___________%
2.
_________________________________________
____________%
___________%
3.
_________________________________________
____________%
___________%
4.
_________________________________________
____________%
___________%
Please list appropriate accommodations needed to accompany the patient’s loss of functioning in each activity:
ACTIVITY
ACCOMMODATION(S) SUGGESTED
____________
______________________________________________________________________________
____________
______________________________________________________________________________
____________
______________________________________________________________________________
____________
______________________________________________________________________________
______ (x) Physician’s comments continue on reverse side of this form.
___________________________________________
Physician’s Name (please print)
THANK YOU!
__________________________________________
Signature
_____________________________________________________________________
Address
City
State
Zip
______________
Date