Verification Form: Medical Conditions

NOTE: This form is to be filled out, in its entirety, by the professional treating the student. This professional must be unrelated to the student, and any information provided by a family member will be considered supplemental. Forms with insufficient detail will prompt a request for more information. PLEASE TYPE AND SUBMIT THIS FORM ELECTRONICALLY, rather than handwriting or printing it out. You will be copied this information by email upon submission.

Student Information
Student Name Student Name First Last
Certification Provider Information
Provider Name Provider Name First Last
Provider Email
Provider Title
License/Certification Number and Issuing State
Provider Address Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Professional Information
Date of Initial Contact with Student: Date of Initial Contact with Student: / MM / DD YYYY
Date of Most Recent Formal Contact/Appointment with Student Date of Most Recent Formal Contact/Appointment with Student / MM / DD YYYY
Approximate Frequency of Contact with Student since Initial Contact
Date of Completion of this Form Date of Completion of this Form / MM / DD YYYY
To ensure the provision of reasonable and appropriate services for students with long-term medical conditions, AccessibleNU requires students to provide current and comprehensive documentation of their condition and its impact on their education. To standardize the gathering of such information, we ask that the student's healthcare provider answer the following questions to assist AccessibleNU staff in their determination of reasonable accommodation.
Please describe the student’s impairment, listing a specific diagnosis (if applicable). Include the date of diagnosis, and explain the labs/tests administered used in the diagnostic process. (AccessibleNU may also request copies of lab/test results.)
What is the expected duration of the condition?
If the student is currently undergoing medical treatment, please describe and indicate how the treatment might affect the student academically.
Describe how this medical condition may result in specific functional limitations in an academic setting (i.e., problems sitting for more than 1 hour, difficulty typing for more than 10 minutes, or inability to walk more than 50 feet without fatigue).
List current medication(s), impact, and any adverse side effects. Is the student still adjusting to or stabilized on the medication(s)?
Provide specific recommendations (based upon your assessment, the student’s clinical and academic history, and diagnosis) for accommodations that you believe will help equalize the student’s ability to access Northwestern University’s educational program.
Please provide any additional information you feel will be useful in evaluating the nature and severity of the student's disability and any additional recommendations that may assist AccessibleNU in determining appropriate accommodations and intervention. (This could entail providing additional documents that include test results or appointment notes, for instance.)
HEALTHCARE PROVIDER INFORMATION
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Full Name

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Date Date / MM / DD YYYY

Verification Form: Medical Conditions

Verification Form: Medical Conditions

Student Information

Certification Provider Information

Professional Information

HEALTHCARE PROVIDER INFORMATION