Medical Condition Documentation Form

Individuals qualified to complete this form are those who have been trained in the assessment and treatment of medical conditions. Recommended practitioners include: physicians; physicians assistants; or other relevant medical personnel qualified to diagnose and treat this medical condition. The diagnostician must be an impartial individual who is not a family member of the student. In order to determine eligibility and to provide services, we require documentation of the student's condition. Please complete only one Physical Health Verification Form for each condition that the student is requesting accommodations. If the student has multiple conditions, we will require a separate form for each condition.

Documentation assists the Office of Disability Services staff to:

  • Establish a student's eligibility for services.
  • Understand the impact of a student’s condition(s) in an academic environment.
  • Determine strategies and reasonable accommodations to facilitate equal access.

Further information on the components of professionally prepared documentation such as: qualified professionals; diagnostic statements; diagnostic methodology; current functioning and current documentation; functional impairment; duration, progression, and stability of a condition; and documentation to support requested reasonable accommodations can be found at the following link: General Documentation Principles and Guidelines . In addition to the requested information, additional relevant documentation can be attached at the end of this form. You will have the opportunity to print or save a copy of your submission at the conclusion of the form for your records. Please contact us if you have questions or concerns. Thank you for your assistance.

Student Information
  • (Used for identification purposes)