One Otterbein University
Westerville, OH 43081-2006
TEL (614) 823-1610
FAX (614) 823-1983
www.otterbein.edu
Academic Support Center
VERIFICATION OF A MEDICAL DISABILITY
The Disability Services Office at Otterbein University provides services to students with diagnosed
medical disabilities. To determine eligibility for services, this office requires current and
comprehensive documentation of this disorder from the diagnosing physician or physician currently
treating the student.
Please answer the following questions pertaining to:
Date of Birth:
Phone #:
1.
What is the diagnosis, date of diagnosis and date of last contact with student?
2.
Is the student/patient currently under your care?
3.
List current medication(s), impact, and any adverse side effects. Please indicate how
these side effects might impact the student academically.
4.
If the student is currently undergoing medical treatment, please describe and indicate
how the treatment might affect the student academically.
Yes
No
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5.
What is the expected duration of this disability?
6.
Major Life Activities Assessment:
Please check which of the following major life activities listed below are affected
because of the impairment. Please indicate severity of limitations.
Life Activity
Negligible
Moderate
Substantial
Don’t know
Talking
Hearing
Breathing
Standing
Caring for Oneself
Reaching
Lifting
Sitting
Walking
Seeing
Writing
Performing Manual Tasks
Sleeping
Learning
Reading
Thinking
Concentrating
Memorizing
Interacting with others
Other:
Other:
7.
Describe how this medical condition may result in specific functional limitations in an
academic setting (i.e. problems sitting for long periods of time, unable to type for more
than ten minutes, or unable to walk more than 50 feet without fatigue)?
Medical_form pg. Page 2 of 3
8.
Are there any situations or environmental conditions that might lead to an exacerbation
of the condition?
9.
Please state specific recommendations regarding academic accommodations for this student,
and a rationale as to why these accommodations/adjustments/services are warranted based
upon the student’s functional limitations. Indicate why the accommodations are necessary.
10.
If the current treatments (i.e. Medications) are successful, state the reasons the above
academic accommodations and/or auxiliary aids are necessary.
Signature:
Date:
Print name and title:
Address:
City, State, Zip:
Telephone:
Return this information to: Kera McClain Manley
Disability Services Coordinator
Otterbein University
Westerville, OH 43081-2006
Phone: (614)-823-1618
FAX: (614)823-1983
Medical_form pg. Page 3 of 3