Date: __________ Term Requested: Fall / Spring / Summer
Dear: _________________________
(Name of Clinician)
Year Requested: __________
I am requesting an accommodation in my residence hall at Northeastern University due to a
(check one)
 Disability  Medical Condition
In order to be considered for an accommodation in my residence hall I must provide documentation to Northeastern of my disability or medical condition. Accommodations in housing assignments are solely based on diagnostic documentation and once this information is in place it will be used to consider my eligibility for such an accommodation.
Specifically I am asking Northeastern for a residence hall placement that: (fill in your specific request here)
____________________________________________________________________
____________________________________________________________________
I hereby authorize you to complete the enclosed Medical Condition Disclosure Form and fax to:
617-373-7800 (fax)
If there are any questions, please email:
Housingaccommodation@neu.edu
Thank you for your assistance in this matter.
Sincerely,
__________________________________________ __________________
Student Signature Date
___________________________ _____________ ________________
Print Name NUID Medical Record ID

Student NUID ____________
For Office Use Only
Date Received:
This form must be filled out by the clinician treating the medical diagnosis indicated on this form.
(Incomplete forms will be mailed back to the student with the incomplete areas indicated)
Student’s Name:
Clinician’s Name:
_________________________________
_________________________________
State Licensure/ Certification#:
Area of Specialty:
_________________________________
Clinician’s phone#: _
The person named on this form is requesting a modification in the NU residence halls.
Diagnosis _______ _______________________________________________________
_______________________________________________________________________
The extent of the disorder is: Mild Moderate Severe
Initial Date of Diagnosis: _________ Date of last clinical contact: ____________
Expected duration of medical condition or disability noted above is:
 Long term: 3-12 months
 Short-term Temporary: 60-90 days
 Temporary: less then 60 days
What is the frequency and duration of symptoms of the student’s condition?
Daily 1/week 1-3/week 1/month 1-3/year
None – symptoms under control with medication Other:
Seasonal

Medications:
Current medications (dosage and side effects):
Current compliance with medical plan:
Does this person create a threat to themselves or others (explain)?
Describe the specific limitation(s) imposed by this diagnosis.
What specific accommodation are you recommending for this student?
Describe how the student would be negatively compromised without the accommodation being requested:
Clinician Signature: ________________________________Date:___________________
Fax this completed form to: 617-373-7800
Revised 3/27/09