CAZENOVIA COLLEGE
HEALTHCARE PROVIDER DOCUMENTATION FOR HOUSING ACCOMMODATION
To the Provider: Students with a temporary or long-term medical disability or condition may submit
documentation in support of a request for special housing accommodations. Such disabilities or
conditions may be of a physical or mental health nature, or may be related to learning impairments.
Please note, on-campus housing generally reaches capacity each fall. For this reason, a private room
assignment, outside the lottery or new student housing process, will only be granted, in rare instances, to
students for whom no other possible accommodation is reasonable. A documented condition alone does
not qualify a student for a private room assignment. Many conditions, including those of a psychological
and learning nature, may be accommodated in other ways. College health and special services personnel
will assess the nature and severity of the condition and recommend appropriate housing accommodations
when the following conditions are met:
1. Adequate documentation has been submitted by a licensed clinician;
2. The proposed accommodations are necessary and reasonable;
3. The director has reviewed the documentation and substantiated the necessity for an
accommodation.
All information that you provide will be handled in confidence according to regulations and should only
be released by you with an accompanying signed release from the student. Please complete all sections of
this request form and return to the address at the bottom of page 2. Thank you for your assistance.
Student/Patient Name:______________________________________________________________
Diagnosis:_________________________________________________________________________
Duration and Current Status of Condition(s):______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How long is this condition likely to exist?
 Lifetime  One year  One Semester  Unknown
 Other___________________________
What are the current functional or daily activity limitations regarding this disability or condition?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
In comparison to the average person in the general population, please rate the severity of the student’s
functional limitations noted above.
 Mild
 Moderate
 Substantial
 Severe
 Unknown
What situations exacerbate the student’s condition(s)? _______________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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CAZENOVIA COLLEGE
Please describe any impact of the condition(s) on the student’s ability to attend or participate in academic
or co-curricular activities? _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please explain why you believe this student could not be housed with a suitable roommate, including any
negative impacts to a roommate.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please describe in detail any special accommodations you feel may be necessary in order for this student
to participate in Cazenovia College’s programs and activities. __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name of Licensed Clinician: ____________________________________________________________
License #: _________________________________
State: ______________________________
Address: _____________________________________________________________________________
Telephone: _________________________________
Fax: _______________________________
Signature: __________________________________
Date: ______________________________
Return to:
Cazenovia College
22 Sullivan St.
Cazenovia, NY 13035
Attn: Campus Health Services
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Spring 2010