PHYSICAL DISABILITY/MEDICAL CONDITION DOCUMENTATION FORM
The student named below has applied for services from the Office of Disability Services (ODS) at Marquette
University. In order to determine this student's eligibility for reasonable and appropriate accommodations, we
ask that you provide current and comprehensive information attesting to the student's disability and
documenting the functional impact of the disability. The information you provide will not become part of the
student's educational records but will be kept in the student's confidential file in ODS.
Please take into consideration when completing this form:
1. All parts of the form must be completed as thoroughly as possible. Inadequate information,
incomplete answers and/or illegible handwriting may delay the eligibility review process by
necessitating follow up contact for clarification.
2. The healthcare provider should attach any reports which provide additional related information. If a
comprehensive diagnosis report is available that provides the requested information; copies of that
report can be submitted for documentation as well.
If you have any questions please call the Office of Disability Services at 414-288-1645. Thank you for your
assistance.
Name of Student: __________________________________________ Birth Date: _____________________
1. Is this student currently under your care? _____Yes _____No
2. When did you last see this student? ____________________________________
3. What is the diagnosis of the impairment? (Please use definitive language and avoid such speculative
language as “suggests” or “could have problems”)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________
a. Date of diagnosis: _______________________________________________________
Major Life Activities Assessment
Please check which of the major life activities listed below are substantially limited because of the current
condition. (Substantially limited is defined as a "significant restriction in the condition, manner, or duration in
which a major life activity is performed compared to most people.")
Talking
Hearing
Breathing
Standing
Working
Reaching
Lifting
Sitting
Walking
Speaking
Seeing
Sleeping
Learning
Thinking
Concentrating
Memorizing
Writing
Interacting w/others
Caring for oneself
Reading
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013
Academic Effects
I.
How does this condition/impairment impact the student’s ability to participate and learn in an
academic setting (i.e. problems sitting for long periods of time, unable to type for more than a
specific amount of time etc)? If this condition/impairment does not affect the student
academically, please progress to section II.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
a. If the student is currently undergoing medical treatment, please describe and indicate how this
treatment might affect the student academically.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
b. Are there any situations or academic environments that might lead to an exacerbation of the
condition/impairment?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
c.
Please provide specific academic accommodations with justification as to why these
accommodations would be appropriate for the student. *Please note - There may be
limitations on the number of absences a student is allowed based on class requirements.
i. Accommodation:_______________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
ii. Accommodation:_______________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
iii. Accommodation:_______________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013
Housing Effects
II. Does this condition/impairment require housing accommodations? If so, please describe the present
symptoms and their current functional limitation in the housing environment.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
a. If the student is currently undergoing medical treatment, please describe and indicate how this
treatment might impact their living environment (i.e. medical devices, refrigeration etc).
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
b. Please identify and explain if there are any housing environments that might lead to an
exacerbation of the condition/impairment (i.e. room temperature, room location etc)?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
c.
Please provide specific housing accommodations with justification as to why these
accommodations would be appropriate for the student.
i. Accommodation:_______________________________________________________________
______________________________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ii. Accommodation:_______________________________________________________________
______________________________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
iii. Accommodation:_______________________________________________________________
______________________________________________________________________________
Justification:___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
*Please Note; private rooms may be provided student as an accommodation for a medical necessity (i.e. the
student requires attended care for toileting or bathing). Because the university provides students a range of
quiet study environments outside of the residence halls and given the social purpose of residence hall living;
private rooms are generally not provided as an accommodation for disabilities.
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013
Is there anything else you would like us to know about this student?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________
Please sign, date and return to our office.
___________________________________________________
________________________
Signature of Treating Professional
Date
___________________________________________________
________________________
Professional's Name (printed) and Title
License Number
___________________________________________________
________________________
Telephone Number
___________________________________________________
________________________
Address
Fax Number
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013