Physician Support Document
TO: Physician/Other Qualified Professional
FROM: The Office of Residential Life, Assumption College

The student who sent you this form has requested that Assumption College provide her/him with a
housing accommodation due to a documented disability (current condition or need). We require that students request such housing accommodations in writing, and we also ask that they provide specific documentation from a specialist in the field who can provide a clear and convincing rationale for the requested accommodation.

All documentation and supporting materials must be received by the Office of Residential Life by June 18, 2019 (late forms will not be reviewed until after housing assignments are completed). You may append additional information to this form. Thank you for your assistance and attention to this matter.

Please note that no requests can be made for a specific living arrangement on campus, unless this documentation supports a medical challenge that would require a specific style of room on campus, or other accommodation due to a disability.

Please note this information is considered confidential and will only be shared with members of the Student Accommodations Committee or, if necessary, the appeals committee as they consider this request.
Please confirm the students name: *
Your answer
What is the student's documented disability? *
Your answer
How long has this student had this condition? *
Your answer
How long have you been treating this student for this specific condition? *
Your answer
When was the last time you provided treatment and evaluated this condition? *
Your answer
What medications, treatments, assistive technology or services if any, have been prescribed to this student?
Your answer
Over the past year, the student's condition has been: *
If the student's condition worsened over the past year, please identify any exacerbating factors that might have led to the present situation.
Your answer
What in your opinion is the expected progression of this condition over time? *
Your answer
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