Disability Documentation Form printable pdf download

Disability Documentation Form

Office of Access and Services for Individuals with Disabilities

Disability Documentation Form

525 West 120

Street, Box 105

General Office: (212) 678-3689

Thorndike Hall, Room 166

Deaf & Hard of Hearing Services:

New York, NY 10027

V/TTY (212) 678-3853

Fax: (212) 678-3793

Part A: Documentation presentation

Student/Employee (please circle one)

, am providing you with clinical documentation of my disability.

Signature

Date

Part B: Medical release

, authorize

to release documentation of my disability to

the Office of Access and Services for Individuals with Disabilities at Teachers College, Columbia University.

Signature

Date

Part C: Disability certification

, authorize

to certify my disability by completing the

form below.

Signature

Date

To be completed by physician, psychologist, audiologist or psychiatrist.

The individual listed above has registered for support services with Teachers College. Please certify that this

individual’s disability includes the following functional limitations as they relate to work or courses of study:

Name

Title

Agency/Hospital

Phone

Address

City

State

Zip

Signature

Date

Please list credentials and/or license information

Disability Documentation Form