Medical Condition Disclosure Form

Housing Accommodation Request Form Date: ______Term Requested: Fall / Spring / Summer Dear: ______Year Requested: ______(Name of Clinician)

I am requesting an accommodation in my residence hall at Northeastern University due to a (check one)

Disability Medical Condition

In order to be considered for an accommodation in my residence hall I must provide documentation to Northeastern of my disability or medical condition. Accommodations in housing assignments are solely based on diagnostic documentation and once this information is in place it will be used to consider my eligibility for such an accommodation.

Specifically I am asking Northeastern for a residence hall placement that: (fill in your specific request here) ______

______

I hereby authorize you to complete the enclosed Medical Condition Disclosure Form and fax to: 617-373-7800 (fax)

If there are any questions, please email: [email protected]

Thank you for your assistance in this matter.

Sincerely,

______Student Signature Date

______Print Name NUID Medical Record ID Student NUID ______

For Office Use Only

Date Received: Housing Accommodation Form

This form must be filled out by the clinician treating the medical diagnosis indicated on this form. (Incomplete forms will be mailed back to the student with the incomplete areas indicated)

Student’s Name: ______

Clinician’s Name: ______

State Licensure/ Certification#: ______

Area of Specialty: Clinician’s phone#: _

The person named on this form is requesting a modification in the NU residence halls.

Diagnosis ______

______

The extent of the disorder is: Mild Moderate Severe

Initial Date of Diagnosis: ______Date of last clinical contact: ______

Expected duration of medical condition or disability noted above is:  Long term: 3-12 months  Short-term Temporary: 60-90 days  Temporary: less then 60 days

What is the frequency and duration of symptoms of the student’s condition?

Daily 1/week 1-3/week 1/month 1-3/year Seasonal

None – symptoms under control with medication Other: Medical Condition Disclosure Form – page two

Medications: Current medications (dosage and side effects):

Current compliance with medical plan:

Does this person create a threat to themselves or others (explain)?

Describe the specific limitation(s) imposed by this diagnosis.

What specific accommodation are you recommending for this student?

Describe how the student would be negatively compromised without the accommodation being requested:

Clinician Signature: ______Date:______Fax this completed form to: 617-373-7800 Revised 3/27/09