Request for Documentation

The person named below has requested accommodations and/or disability/related services at University of Minnesota, Morris (UMM). In order to be eligible to use accommodations, the individual must have a documented disability, as defined by federal law.

The Disability Resource Center will use the information you provide to determine whether this person has a disability and is eligible to use accommodations and/or disability-related services while attending UMM. In addition, the functional information you provide will assist disability services in identifying the appropriate accommodations for this individual.

Medical Professional/Diagnostician Completes:

Name

Student ID

Date of Birth

Diagnosis (i.e. DSM V or medical):

Date of most recent evaluation:

Name and title of evaluator:

List diagnostic protocol used:

*If the diagnosis is a learning disability, please attach the current psycho-educational evaluation.

Upload psycho-educational evaluation (if applicable)

Describe the severity of the disability, and the student’s functional limitations in an educational setting:

Will the functional limitations described above change over time? Yes / No

If yes, please explain:

If appropriate, list the treatments, medications, assistive devices, accommodations or services currently prescribed or in use and describe their impact or expected impact:

Recommendations from professionals who have worked with this person provide valuable information we can use when determining the specific accommodations and/or disability-related services for this individual. Please list any suggestions for accommodations/services you wish to make.

If your suggestions go beyond what can be appropriately provided at UMM, we may use your information to suggest referrals to other service providers.

I certify that the information submitted represents this person’s present level of functioning.

Signature of the Professional

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Organization and Address

Request for Documentation

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