Student Accessibility Services Phone: 401-254-3281 Scan and Email: sas@rwu.edu Mail to: SASMain Library 1st FloorOne Old Ferry Road, Bristol, RI 02809

The student below is requesting disability-related accommodations from Roger Williams University, through the Student Accessibility Services Office (SAS). We are looking for your expertise about and individualized assessment of their condition.

The ADA Amendments Act of 2008 defines disability as a current, longstanding condition that substantially limits a major life function (such as, but not limited to concentration, learning, seeing, hearing, walking, etc.) or a major bodily function/system (such as but not limited to immune, respiratory, cell division, digestive, bowel, neurological, brain, circulatory, etc). Not all conditions qualify as a disability, but an individualized assessment can help establish the nature of the condition, the severity and duration of the condition, and the level of impact to a major life or major bodily function in the educational or physical environment.

Please download, complete and sign this form. Emailing or mailing the form to us will help the SAS staff determine the presence of a disability for this student. Your information will also help us understand the particular ways that we can support the student’s equal opportunity and inclusion in all aspects of student life and education at Roger Williams University.

Thank you for your time, The Staff of Student Accessibility Services.

Today’s Date: ______________________

Name of student: _____________________________________________________

Date of Birth: _________________________________

Primary Diagnosis: ____________________________________ Date of Initial Diagnosis____________

Secondary Diagnosis: ___________________________________Date of Initial Diagnosis____________

Testing: Please attach report(s)Clinical Evaluation

Direct Interview with student

Interviews with other person

Diagnostic Procedure(s) (lab, MRI, CT, etc)

Eductional

Psychological

Neuro-psychological

How was the diagnosis determined? (Please check all that apply):

Roger Williams University

Verification of Disability

Dear Practitioner:

MinimalImpact of Conditions

Significant Severe-Profound

Life Functions:

Walking

Hearing

Seeing

Concentrating

Managing Stress

Reading/Learning

Other:

Bodily Functions:

Neurological

Respiratory

Circulatory

Digestive or Bowel

Immune System

Allergic Condition

Other:

Description of the Progression or Stability of the condition over time and in context:

License #:

State: Zip:

Practitioner Name:

Address:

City:

Phone and Extension #:

Practitioner Signature:____________________________________________________

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