Documentation Guidelines
The Accessibility Center (AC) at Southern New Hampshire University (SNHU) facilitates
academic and programmatic services and accommodations for students with documented
disabilities. Accommodations are determined on a case-by-case basis that is based on both a
review of the documentation provided and an intake appointment with an Accommodations
Specialist.
Documentation provided should:
•
•
•
•
List an identifying factor such as students name and/or date of birth.
List the diagnosis or disability.
Be completed by a qualified professional.
Explain the current impact of the disability.
Although the Accessibility Center will review and consider all documentation submitted, the
Accessibility Center will make the final determination of whether reasonable accommodations
are substantiated and can be provided to the individual. If the documentation submitted does
not support the need for the requested accommodations, further documentation may be
requested.
There are several ways to provide Accessibility Center with documentation of a
disability:
•
A detailed evaluation or diagnostic report and plan. Typically, these reports will
include information on the student’s levels of aptitude, achievement, and information
processing. These reports are recommended for students with Learning Disabilities,
ADD/ADHD, and Autism Spectrum Disorder.
•
A plan that provides proof of prior accommodations.
•
Completion of SNHU’s Disability Verification Form (pages 2-4) by an appropriate
health care professional.
•
A letter from a health care professional. This information should be provided on
official letterhead with the date and signature of the qualified professional.
Inquiries may be directed to the
Online - Accessibility Center | 866.305.9430 | Fax: 877.520.8916 | oac@snhu.edu
Campus - Accessibility Center│ 603.644.3118│ Fax: 603.644.3132 | cac@snhu.edu
6/2022
(Please type or print clearly)
Student’s Name
Address:
12171983
allyan ann hinojosa
________________ Date of Birth: _______
Student ID:
2423164
APT 411
160 west _________________________________________________________________
10th street
chicago
HEIGHTS ILLINOIS 60411
_____________________________________________________________________________
Email: ALLYAN.HINOJOSA@SNHU.EDU
Cell Phone: 7085716349
Other Phone:
7087542220
Diagnostic Information
(To be completed by the appropriate health care professional)
Provider Name:
THORTION
HEIGHTS TERRACE
______________________________________________________________________
Provider Title:
______________________________________________________________________
160 WEST 10TH STREET, CHICAGO HEIGHTS ILLINOS
Address: _______________________________________________________________________________
_________________________________________________________________________________
Provider Phone:
708 754 2220
_______________________________________________________________________
708 754 9311
Provider Fax: ____________________________________________________________________________
LEARNING DISABILITY, ADD and EPLIPSY
Diagnosis/Disability: ________________________________________________________________
_______________________________________________________________________________________
SINCE DECEMBER 17,1983
Date of Onset: ___________________________________________________________________________
Severity of the Impact:
(Mild)
(Moderate)
(Severe)
Please state any medication(s) the student is prescribed and if it alleviates functional limitations or if it
contributes to functional limitations:
Folic _______________________________________________________________________________________
acid 4 tabs(4mg) daily at 9:00am ,Quetiapine tab 400mg daily at 9;00am, Carbamazepin tab 200mg take 2 tab
by mouth
three times daily ,lactulose sol 10gm/15 take45ml (30gm) by mouth twice daily , Lamotrigine tab100mgtake 1 tablet
_______________________________________________________________________________________
twice daily levetiractam tab 750mg take 1 tablet by mouth twice daily,
Has the student been hospitalized within the last calendar year? _____________________________________
YES
Provider should complete pages 2-4, sign and date page 4, and include any reports with additional
information. If a comprehensive report is available providing the information requested, it can be
submitted for documentation instead of this form.
Inquiries may be directed to the
Online - Accessibility Center | 866.305.9430 | Fax: 877.520.8916 | oac@snhu.edu
Campus - Accessibility Center│ 603.644.3118│ Fax: 603.644.3132 | cac@snhu.edu
6/2022
Impairment in Major Life Activities:
Life Activity
Unknown/
Not Applicable
Mild
Mobility
GREAT
YES
Concentration
GOOD
YES
Memory
GOOD
Social Interactions
GOOD
YES
GROUPS
YES
Organization
Attendance
GREAT
Reading
GOOD
Writing
GOOD
Thinking (processing
speed)
SLOW
Communicating
FAST
Time Management
Stress Management
Managing internal
distractions
Managing external
distractions
NO
SOME
NO
NO
NO
YES
YES
YES
NO
YES
NO
Eating
GOOD
NO
Sleeping
GOOD
NO
Self-care
GREAT
NO
NO
NO
NO
NO
NO
NO
NO
SOME
NO
NO
YES
NO
NO
NO
YES
NO
NO
NO
NO
NO
NO
NO
NO
YES
Severe
NO
NO
YES
NONE
NONE
NO
YES
SOME
Speaking
Moderate
YES
NO
YES
NO
YES
NO
YES
NO
YES
Inquiries may be directed to the
Online - Accessibility Center | 866.305.9430 | Fax: 877.520.8916 | oac@snhu.edu
Campus - Accessibility Center│ 603.644.3118│ Fax: 603.644.3132 | cac@snhu.edu
6/2022
Verification Form
Please describe any major activities impacted by the diagnosis or symptoms that may need
to be addressed in the college residency environment:
________________________________________________________________________________________
cheer leading , singing ,music and tv
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________
Please state specific recommendations regarding accommodations for this student:
EXTENDETED TIME ON HOME WORK AND TESTS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________
Please describe student strengths and add any additional comments you feel are appropriate:
TAKING HER MEDS AND STUDY AND SLEEP AND EXCERSIZE AND EAT DAILY
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________
Signature: __________________________________________________
10/3/2022
Date: ____________________
Inquiries may be directed to the
Online - Accessibility Center | 866.305.9430 | Fax: 877.520.8916 | oac@snhu.edu
Campus - Accessibility Center│ 603.644.3118│ Fax: 603.644.3132 | cac@snhu.edu
6/2022