University of Virginia

Learning Needs and Evaluation Center

VERIFICATION OF MEDICAL CONDITION OR DISABILITY

I, the undersigned, certify that:

Name of Student: __________________________________________________________

SSN#: ___________________________________________________________________

Address: _________________________________________________________________

_________________________________________________________________________

Please mark the most appropriate description for this individual:

[  ]  meets the definition for a disability as defined by ADA and Section 504 by reason of the following limitation

[  ]  has a medical condition for which academic accommodations may be appropriate.

1.  Diagnosis/Description of Medical Condition or Primary Disability:
 
 
 
 
2.  Functional Limitations (e.g., limited ambulation; visual acuity; degree of hearing loss):
 
 
 
 
3.  Current Treatment(s)/Therapy and Prescribed Medications and Dosage:
 
 
 
 
4.  The medical condition or disability above is:
 [  ]  Permanent/Chronic
 [  ]  Short-term Temporary - 45 days or greater
 [  ]  Temporary - less than 45 days
 
5.  The condition or disability is: [  ]  Observable       [  ]  Not Observable
 
6.  Please list special assistance you recommend:
 
 
 
 
Complete records are on file at the below location and will be available upon request.
 
                                                                                                     
Signature                                                                Date
                                                                                                     
Title
                                                                                                     
Name of Agency
                                                                                                     
Phone Number
 
                                                                                                     
Street Adress
                                                                                                     
City/State/Zip
 
Please return to:

Allison Anderson, Ph.D.
Director, Learning Needs and Evaluation Center
University of Virginia
Elson Student Health Center
400 Brandon Avenue
PO Box 800760
Charlottesville, VA 22908-0760
Phone:  (434) 243-5180
Fax:  (434) 243-5188