OFFICE FOR STUDENTS WITH DISABILITIES
9500 GILMAN DRIVE DEPT 0019
TEL: (858) 534-4382
LA JOLLA CALIFORNIA 92093-0019
FAX: (858) 534-4650
TDD: (858) 534-9709
Documentation Form for Medical Conditions
The student below has requested accommodations on the basis of a Medical Condition through the
Office for Students with Disabilities (OSD) at UC San Diego.
In order to verify the disability, its severity, its impact on one or more major life activities, and to
determine reasonable accommodations, your diagnosis and assessment of this student is
needed. Documentation must be current (i.e. most recent visit should be within the last 3 months).
Please attach any supporting documentation (audiology reports, optometry exams). All information will
be kept confidential.
Name/Title of Certifying Professional (Please Print)
I certify, by my signature below, that I conducted or formally supervised and co-signed the diagnostic
assessment of the student named above. In cases where the diagnostic assessment of the student was
performed by another clinician, my signature confirms the review of the original assessment and
agreement of the diagnosis.
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