Documentation Form For Medical Conditions printable pdf download

Documentation Form For Medical Conditions

OFFICE FOR STUDENTS WITH DISABILITIES

9500 GILMAN DRIVE DEPT 0019

TEL: (858) 534-4382

LA JOLLA CALIFORNIA 92093-0019

FAX: (858) 534-4650

WEB:

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.

Student Name

DOB

Name/Title of Certifying Professional (Please Print)

License #

State

Address

Telephone Number

Fax Number

Provider Certification:

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.

Signature

Date

DocFormMedicalConditions_090913

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Documentation Form For Medical Conditions