ODS Home Page

 

                                                                        Office of Disability Services

Eastern Illinois University

600 Lincoln Avenue

Charleston IL 61920-3099

217-581-6583 (Voice/TTY)

217-581-7208 (Fax)

 

PHYSICAN’S STATEMENT

TO DETERMINE ELIGIBILITY FOR A FUNCTIONAL OR PHYSICAL IMPAIRMENT

 

Please return the completed form to the Assistant Director of Disability Services at the above address.

 

Student Name:  ___________________________________              Today’s Date: ____________

 

The above named individual is a student at Eastern Illinois University.  S/he is requesting support services/accommodations for a physical or functional disability.  The University is committed to providing reasonable accommodations and academic support to all students who have a disabling condition as defined by federal legislation (the 1973 Rehabilitation Act [Section 504] and the 1990 Americans with Disabilities Act).  University policy requires that students requesting such assistance provide verification of disability from the student’s attending physician.  The documentation must be submitted to the Office of Disability Services in a reasonable amount of time for the University to provide the necessary accommodations.

 

Under the Americans with Disabilities Act, an individual with a disability is any person who:

 

  1. Has a physical or mental impairment which substantially limits one or more major life activities;
  2. Has a record of such impairment; or,
  3. Is regarded as having such an impairment.

 

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Please provide the following information:

 

Diagnosis: ____________________________________________________________________

 

Date of initial diagnosis: _______________________  Date of last visit: _______________

 

How often do you meet with this individual? _________________________________________

 

Frequency of episodes: __________________________________________________________

 

Severity of episodes: ____________________________________________________________

 

Please complete the reverse side of this form.

 

 

Dates of hospitalizations and emergency room visits for this condition: ____________________

______________________________________________________________________________

 

What situations are likely to immediately trigger an episode of this condition (e.g. low sugar levels, smoke, etc.)? _____________________________________________________________

 

What repetitive situations are likely to trigger an episode of this condition? _________________

______________________________________________________________________________

 

Current treatment for this condition: ________________________________________________

____________________________________________________________________________________________________________________________________________________________

 

List any medication(s) prescribed and side effects experienced: ___________________________

____________________________________________________________________________________________________________________________________________________________

 

Please check all major life activities that are affected by this condition:

ÿ breathing       ÿ walking         ÿ hearing          ÿ seeing           ÿ working        ÿ learning        

ÿ performing manual tasks        ÿ caring for oneself                   ÿ no major life activities are affected

 

What are the functional limitations of the disability?  ___________________________________

______________________________________________________________________________

 

List accommodations you would recommend relative to the disability:  ____________________

______________________________________________________________________________

 

Please list pertinent testing that helps to confirm diagnosis:

Test                                                      Date                                         Results

 

 

 

 

 

 

 

Please attach medical information that is needed to substantiate a disability and the need for accommodations (i.e., current medical records, additional copies of test results etc.)

 

Thank you for your help in providing this information so that we may begin providing services as soon as possible.  Please return this form to the address shown on the letterhead.

 

 


Physician’s signature: ___________________________________________________________

 

Printed name and title: ___________________________________________________________

 

Office address: _________________________________________________________________

 

Office telephone: ______________________________          Date: _________________________