<p> Housing Accommodation Request Form Date: ______Term Requested: Fall / Spring / Summer Dear: ______Year Requested: ______(Name of Clinician) </p><p>I am requesting an accommodation in my residence hall at Northeastern University due to a (check one) </p><p>Disability Medical Condition</p><p>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. </p><p>Specifically I am asking Northeastern for a residence hall placement that: (fill in your specific request here) ______</p><p>______</p><p>I hereby authorize you to complete the enclosed Medical Condition Disclosure Form and fax to: 617-373-7800 (fax)</p><p>If there are any questions, please email: [email protected]</p><p>Thank you for your assistance in this matter.</p><p>Sincerely,</p><p>______Student Signature Date</p><p>______Print Name NUID Medical Record ID Student NUID ______</p><p>For Office Use Only</p><p>Date Received: Housing Accommodation Form</p><p>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)</p><p>Student’s Name: ______</p><p>Clinician’s Name: ______</p><p>State Licensure/ Certification#: ______</p><p>Area of Specialty: Clinician’s phone#: _</p><p>The person named on this form is requesting a modification in the NU residence halls.</p><p>Diagnosis ______</p><p>______</p><p>The extent of the disorder is: Mild Moderate Severe</p><p>Initial Date of Diagnosis: ______Date of last clinical contact: ______</p><p>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</p><p>What is the frequency and duration of symptoms of the student’s condition?</p><p>Daily 1/week 1-3/week 1/month 1-3/year Seasonal</p><p>None – symptoms under control with medication Other: Medical Condition Disclosure Form – page two</p><p>Medications: Current medications (dosage and side effects):</p><p>Current compliance with medical plan:</p><p>Does this person create a threat to themselves or others (explain)?</p><p>Describe the specific limitation(s) imposed by this diagnosis.</p><p>What specific accommodation are you recommending for this student?</p><p>Describe how the student would be negatively compromised without the accommodation being requested:</p><p>Clinician Signature: ______Date:______Fax this completed form to: 617-373-7800 Revised 3/27/09</p>