Documentation Of Disability Form printable pdf download

Documentation Of Disability Form

North Carolina State University is a land-

Office of the Provost

grant university and a constituent institution

of the University of North Carolina

Division of Academic and

Student Affairs

An Equal Opportunity/Affirmative Action Employer

DOCUMENTATION OF DISABILITY FORM:

Disability Services Office

Student Health Center

2815 Cates Avenue, Ste. 2221

Must be completed by your diagnostician to document legal disability

Campus Box 7509

Raleigh, NC 27695-7509

status and appropriate academic accommodations.

919.515.7653 (voice)

919.513.2840 (fax)

Student Name

Date of Birth

Diagnoses (with codes, date of initial, most recent, and frequency of office visits/treatment:

II.

Current Disability Limitations (including medication side effects) with severity and frequency) and How They

Affect Learning:

Expected Duration:

III.

Past and/or Recommended Accommodations and Why They are needed:

Title

Name

Address/Phone/Fax/E-Mail

Signature_____________________________________Date_______________________________

Attach evaluation report if available. *Clinic notes do not usually contain the relevant

information needed.

Documentation Of Disability Form