Disability Services
SUPPORTING DOCUMENTATION FORM
A student seeking support for a disability or medical condition must be able to provide appropriate
documentation. In conjunction with an interview with the Disability Adviser, this documentation assists in
understanding the impact of the student’s disability or medical condition on academic performance and in
determining what facilities, services and educational adjustments may be appropriate.
Please refer to the “Documentation Guidelines” for advice on the appropriate medical professionals. For
further details of the documentary requirements, refer to the Disability Services Documentation Guidelines:
http://students.acu.edu.au/301971
Please note: This form should not be used for students with Learning Disabilities, for which a
comprehensive report by an appropriately qualified psychologist or psychiatrist must be provided.
Student Authority for Provision of Information (to be completed by student)
I, (print full name)……………………………………………………………… Student ID: ……………………….
give permission for the Health Practitioner to provide the information below and in any attachments.
Student Signature: ……………………………………………………………………………… Date: …………………………
TO BE COMPLETED BY HEALTH PRACTITIONER
Student Name:………………………………………………………..
Clinical Diagnosis (based on relevant diagnostic criteria):
Duration of condition: From / /
To / /
Disability Status
Is the condition:
 Permanent
 Temporary – please specify the anticipated
duration of the condition:
Is the condition:
 Stable
 Fluctuating
 Degenerating
 Improving
Is the condition:
 Mild
 Moderate
 Severe
 Improving
Symptoms:
Treatment (including any therapy, medication and side-effects):
Are there any other reports, referrals or mental health plans available for you to provide?
If yes, please tick here and attach.
Impact of condition/s on academic performance (eg: concentration, memory, fatigue, motivation,
nausea, mobility, visual acuity, residual hearing):
Other comments or recommended strategies for reasonable adjustment:
Alternative formats:
Assistive technology/equipment:
Exam adjustments:
Scheduling & attendance:
Accessibility needs:
Placement/fieldwork adjustments:
Physical adjustments:
Assignment support:
Other:
Duration of health practitioner treatment of student:
Practitioner Name:
Qualifications/Title/:
Provider Number:
Phone Number:
Address/Practitioners Stamp:
Practitioner’s Signature:
Date
Last Review Date: January 2016