Student Accessibility Services

DISABILITY VERIFICATION

PHYSICAL DISABILITY VERIFICATION
(to be completed by current physician/specialist)

Student Accessibility Services at Kent State University provides support services to students with diagnosed disabilities, including physical disabilities. To ensure the provision of reasonable and appropriate accommodations for our students, this office requires current and comprehensive documentation of the disability from their current physician or specialist. his should include information which describes the onset of the disability, areas affected, and recommendations for the future. Thank you for your assistance.

Student Name:_____________________________________________

1. Please describe the disability (including specific diagnosis):

_____________________________________________________________________________

2. Onset of disability:______________________________________________________

Date of last contact with student:__________________________________________

3. Describe the physical limitations experienced by this student due to this disability:

______________________________________________________________________________

4. Describe how this disability may affect this student academically:

______________________________________________________________________________

5. List current medication, dosage, frequency and possible adverse side effects:

______________________________________________________________________________

6. List any recommendations for accommodations in an academic setting you have for this student (i.e. extra time for exams, different type of chair, lighting, etc.):

______________________________________________________________________________

7. Please describe any specific concerns you may have, or ways that we may be of further assistance to this student:

______________________________________________________________________________

Signature:_________________________________ Date:_______________________________

Printed Name and Title:___________________________________________________________

Address:______________________________________________________________________

City:__________________________ State:_______________________ Zip_________________

Phone: ( _____) ________________________________

Please return this form to:

Student Accessibility Services
Kent State University
Ground Floor DeWeese Center
Kent, Ohio 44242-0001

Phone: 330-672-3391 / Fax: 330-672-3763

PHYSICAL DISABILITY VERIFICATION (to be completed by current physician/specialist)

PHYSICAL DISABILITY VERIFICATION
(to be completed by current physician/specialist)