ATTENTION-DEFICIT/HYPERACTIVITY DISORDER DOCUMENTATION FORM
The student named below has requested 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 us current and comprehensive information attesting to the
student's disability and documenting the functional impact of the disability. The information you
provide will be kept in the student's confidential file at ODS.
In addition to the requested information sought from this form, please attach copies of any test results
or evaluations conducted as part of your diagnostic process.
Name of Student: ______________________________________Birthdate:
______________________
1. Do you see this student on a regular basis? ____ Yes ____ No
When was your last contact with this student? ___________________________
2. What is your DSM-V diagnosis for this student?
3. Please check which of the skills listed below are substantially limited because of the student's
ADD/
ADHD.
* 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."
1) Time management
_____
2) Organizational skills (physical and/or cognitive)
_____
3) Task persistence
_____
4) Memory skills
_____
5) Reading (fluency, comprehension)
_____
6) Quantitative skills
_____
7) Written expression
_____
8) Employment/work skills
_____
9) Self-esteem/social skills
_____
10) Concentration
_____
11) Other
_____
Please list. ____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. What methods or testing instruments did you use to arrive at your diagnosis?
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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 07/2014
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Structured or unstructured clinical interviews with the individual
Interviews with other individuals
Developmental history
Medical history
Neuropsychological / Psych-educational testing
Date(s) of testing? _______________ Copy of testing results attached? _____Yes ____ No
Standardized or non-standardized rating scales
Other (please specify) ___________________________________________________________
_____________________________________________________________________________
5. Do you consider this student's ADD/ ADHD to be a disability? _____ Yes _____ No
6. What medications have been prescribed for this student?
Medication / dosage:
Date first prescribed:
If this student is on medication for ADD/ADHD, what functional limitations does the student
encounter? __________________________________________________________________
___________________________________________________________________________
7. What accommodations do you recommend for this student?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. Is there anything else you would like us to know about this student?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please sign, date and return to our office. Thank you for your assistance.
__________________________________________________
________________________
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 07/2014