Health Care Form - Providence College (Page 3 of 4) in pdf

Health Care Form - Providence College Page 3

Medical/Health Care Provider Fills Out and Signs Section Below:

Please Print or Type:

Student’s Name: ________________________________________________________

Provider Completes the Section Below:

Providence College provides reasonable accommodations and support services to

students with diagnosed disabilities. A student’s documentation regarding their condition

must demonstrate they have a disability covered under the Americans with Disabilities

Act (ADA; 1990). *The ADA defines a disability as a physical or mental impairment

that substantially limits one or more major life activities. To determine eligibility for

services and accommodations, this office requires current and comprehensive

documentation of the student’s disorder from the diagnosing physician or health care

provider (the provider completing this form cannot be a relative of the student). Items 1

through 6 must be completed in full. If space provided is not adequate, please attach a

separate sheet of paper. The provider may also attach a report providing additional

related information.

Please respond to the following items regarding the student named above:

1. What is the current diagnosis of the student’s medical condition including methods

used to arrive at the diagnosis?

________________________________________________________________________

A. How long has the student had this condition?

_______________________________________________________________

B. What is the severity of the condition?

__________________________________________________________________

C. How long is this condition likely to persist?

_______________________________________________________________

2. Describe the substantial limitation of a major life activity as a result of the students

condition:

Health Care Form - Providence College Page 3