UNIVERSITY OF WISCONSIN-MILWAUKEE

Student Accessibility Center
Mitchell Hall, Room 112, P.O. Box 413,  Milwaukee WI 53201
Tel: (414) 229-6287          Fax: (414) 229-2237

Certification of Physical Disability and/or Functional Limitation Due to Medical Condition

Dear Medical Professional:  The student named below has applied for services from the Student Accessibility Center (SAC) at UWM. In order to provide reasonable and appropriate services for students with disabilities, current and comprehensive information documenting the functional impact of the disability is required. This form is intended to assist clinicians in providing sufficient information so that eligibility for services can be determined. The information you provide will not become part of the student’s educational records and will be kept in the student’s confidential file at SAC. In addition to the requested information, please attach any additional information; for example, your report and any test results. Thank you for your assistance.

Date:                          

Name of Student:                                                                                      

  1. What is the diagnosis/impairment:


  2. Date of diagnosis/impairment:                                       

  3. Is the patient/student currently under your care?                               

  4. When did you last see the patient/student:                                       
  1. Major Life Activities Assessment:
Please check which of the major life activities listed below are affected because of the impairment. Please indicate level of limitation.
Life Activity
1 - Negligible
2 - Moderate
3 - Substantial
Talking
checkbox checkbox checkbox
Hearing
checkbox checkbox checkbox
Breathing
checkbox checkbox checkbox
Standing
checkbox checkbox checkbox
Working
checkbox checkbox checkbox
Reaching
checkbox checkbox checkbox
Lifting
checkbox checkbox checkbox
Sitting
checkbox checkbox checkbox
Walking
checkbox checkbox checkbox
Seeing
checkbox checkbox checkbox
Writing
checkbox checkbox checkbox
Performing Manual Tasks
checkbox checkbox checkbox
Sleeping
checkbox checkbox checkbox
Learning
checkbox checkbox checkbox
Reading
checkbox checkbox checkbox
Thinking
checkbox checkbox checkbox
Concentrating
checkbox checkbox checkbox
Memorizing
checkbox checkbox checkbox
Interacting with Others
checkbox checkbox checkbox
Caring for Oneself
checkbox checkbox checkbox




Other:




checkbox checkbox checkbox

checkbox checkbox checkbox
  1. What are the specific functional limitations resulting from the impairment's impact on the major life activities identified above (i.e., unable to lift more than 1- lb.; unable to keyboard more than 10 minutes out of 60 minutes)?


  1. Are these limitations permanent?  If not, what is the anticipated date of resolution?

  1. Medications, effects, and possible side-effects:

  1. If student is currently undergoing treatment, please describe the treatment and how treatment may affect the student in a post-secondary setting.

  1.  Please indicate which accommodations, if any, may be beneficial to this student.
checkbox  Distraction free test environment
checkbox  Extended test time
checkbox  Notetaking support
checkbox  Tape recorded textbooks
checkbox  Reduced credit load
checkbox  Other
  1. Is there anything else you would like us to know about this student?




                                                                                                                                  
Signature of Professional                                                                         Date

                                                                                                                                   
Professional's Name (printed) and Title                                                   License No.

                                                                                                                                   
                                                                                                               Telephone No.

                                                                                                                                    

Address                                                                                                    Fax No.