Services for Students with Disabilities – Vona Academic Annex
Student Health Center – Poyda Hall
2083 Lawrenceville Road
Lawrenceville, NJ 08648
Housing Accommodation Request
for Students with Disabilities or Severe Medical Problems
Directions:
Students:
 Complete Part I
 Sign the Consent for Release of Information on p. 2
 Provide Part I and Part II to your disability evaluator or physician
 If you are requesting housing accommodations only for asthma or allergies, submission of Part I and
Part II of the Request will make your application complete.
 If you are requesting housing accommodations for disabilities including, but not limited to, Asperger’s
Syndrome, Chronic Medical/Health disabilities, or Psychological/Psychiatric disabilities, you must ask
your disability evaluator or physician to complete the appropriate disability documentation form in order
to make your application complete. These forms are located on the Rider.edu/SSD or Rider.edu/Health
websites.
Disability Evaluators and Physicians:
 Complete Part II
 If the requested accommodations are based on a disability other than asthma or allergies, the student will
provide you with an additional disability documentation form. Complete all additional forms provided
to you by the student.
 Return the entire Housing Accommodation Request and the documentation form (as appropriate to the
specific disability) to Services for Students with Disabilities by email or the US Postal Service.
Part I: Student to complete the following:
Name (please print clearly):
Bronc ID#:
Home Address:
Student Cellular #:
Student Home Phone #:
Rider Email:
Status/Campus:
Accommodation Request is for:
Student’s Name:______________________________
1. State the disability for which you are requesting a housing accommodation:
Housing Accomm Request Form 2013
Updated January 2013
2. What disability housing accommodation are you requesting?
3. Have you had this accommodation at Rider University in the past?
4. Please describe how this accommodation will reduce the impact of your disability in the residence halls.
5. Please add any other information you feel is important for us to consider in reviewing your request.
6. Would you like Services for Students with Disabilities to contact you regarding disability related academic
accommodations or support services? Yes No
Student Signature:
_________________________________
Date:_________________
Consent for Release of Information (to be completed by student):
I authorize
____ (physician or evaluator’s name) to disclose the information
requested by this form to the Services for Students with Disabilities Office and Student Health Center of
Rider University for the purpose of evaluating my request for housing accommodations. I also allow
both parties to discuss any information related to my housing accommodation request.
Student Signature:__________________________________________Date:___________
Document1
Updated January 2013
2
Student’s Name:______________________________
Part II: Physician or Disability Evaluator to complete the following:
PROFESSIONAL EVALUATION OF DISABILITY
Accommodations are only available to students identified as having a disability or severe medical problem.
A disability is defined under the Americans with Disabilities Act as “a physical or mental impairment
that substantially limits one or more major life activities.”
Examples of major life activities are: Major bodily functions, seeing, hearing, eating, sleeping, walking,
standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating,
working, performing manual tasks, and caring for oneself.
1. Based on this definition does the individual have a disability?
Yes
Date of original diagnosis:
Date of most recent evaluation:
Is the student currently under your care?
Yes
No
No
2. State the student’s disability diagnosis, including diagnostic code.
3. Check any areas of functioning impacted by the disability. Explain the limitation. Circle the degree of
limitation.
Area of Functioning (check)
 Hearing
 Vision
 Speech
 Manual Dexterity
 Ambulation
 Motor Coordination
 Activities of Daily Living
 Endurance
Document1
Limitation on Functioning (explain)
Degree of limitation (circle)
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Updated January 2013
3
Student’s Name:______________________________
 Respiratory
 Climatic/Environment
 Cognitive Skill
 Sleep
 Social Interaction
 Eating
 Other
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
4. Describe the student’s functional limitations or behavioral manifestations that you would foresee in a college
residential hall setting. What do you foresee as the impact?
5. What is the expected duration, stability, or progression of the disability?
6. Please describe current treatments, prosthetic devices, and or medications prescribed.
7. Is the disability mediated or controlled by medications, other treatments, or external prosthetics?
Yes
No. Please explain:
Document1
Updated January 2013
4
Student’s Name:______________________________
8. Please state specific recommendations for reasonable housing accommodations to address the functional
limitations noted above.
9. What housing accommodations do you consider to be preferred but not medically necessary?
Document1
Updated January 2013
5
Student’s Name:______________________________
If the disability is asthma or allergies, please provide additional information specific to the student’s
health condition using the sections below. Air conditioning requests should be made only for extreme
medical circumstances.
ASTHMA
1. Current diagnosis (select one):
2. Current Asthma Medications (please note medication(s) name and dosage):
-acting Beta Agonists
-Acting Beta Agonists
Inhaled corticosteroids
3. Please check any of the following which are true for your patient (dates required):
xacerbation (3 most recent visit dates)
-acting beta agonist per month: Yes or No
4. Are symptoms:
continuous
5. Severity of symptoms:
mild
intermittent
seasonal
moderate
significant
other (please explain)
other (please explain below)
ALLERGIES
1. Current Diagnosis:
Seasonal Perennial
Allergic conjunctivitis
2. Current Allergy medications (including medication name and frequency of daily use):
3. Please check any of the following which are true for your patient (dates required):
4. Are symptoms:
continuous
5. Severity of symptoms:
Document1
mild
intermittent
moderate
seasonal
significant
other (please explain):
other (please explain)
Updated January 2013
6
Student’s Name:______________________________
THIS SECTION MUST BE COMPLETE FOR FORM TO BE VALID
Physician or disability evaluator INFORMATION (Please Print)
Name:
Title:
Specialty:
Office Address:
Phone:
How long have you treated this patient?
Date of most recent office visit?
May we contact you if we have questions about this student’s accommodation request?
Yes
No
Signature:
Date:
PROVIDER:
 Please include a copy of your letterhead OR
 A voided prescription OR
 Use your office stamp on this document
Stamp
PLEASE MAIL or EMAIL COMPLETED FORM TO:
Services for Students with Disabilities
Joseph P. Vona Academic Annex, Room 8
2083 Lawrenceville Road
Lawrenceville, NJ 08648-3099
Phone: 609-895-5492
Email: serv4dstu@rider.edu
Document1
Updated January 2013
7