Student Disability Services Documentation Form

Please note: A clinician with expertise in the area of the condition following best practices in the field and not related to the student should complete this form.

In order for us to provide disability-related services and accommodation, we need to establish that this individual has a physical or mental impairment that limits one or more of the major life activities, understand the impact of that disability in higher education settings, and determine reasonable accommodations and services that may assist in ameliorating these impacts. Complete documentation guidelines are available at:

Today’s Date:

First Name:

Last Name:

JHU School:

Student Status (circle): Undergraduate Graduate Medical Other:

Diagnosis (if known)/Description of the Functional Impact (required)
  1. Please state the condition/diagnosis:

2. How did you arrive at your diagnosis? Please check all relevant items below:

  • Structured or unstructured Interview
  • Interviews with others
  • Behavioral Observations
  • Medical tests
  • Medical history
  • Developmental history

3. Describe the relevant, current impact of the condition on the student in a higher education setting (academic, housing, dining, transportation, social, etc…):

History and Prognosis (to the degree known):

  • Date condition was first diagnosed
  • Date individual first seen for the condition
  • Date most recently seen for this condition
  • How long do you anticipate the impact
    • 3 months
    • 6 months
    • 1 year
    • More than one year
    • Other
  • Anticipated return to work date
  • The condition is
    • Stable
    • Improving
    • Worsening
    • Cyclically variable
    • Other
  • The prognosis is
    • Poor
    • Fair
    • Good
    • Excellent
    • Other
  • How often is this individual seen
    • Weekly
    • Monthly
    • 3-6 months
    • Yearly
    • Other

4. If the individual is currently taking medication that has side effects and any impact on functioning, please describe below. Do limitations/symptoms persist even with medications?

  • Medication and Dosage
  • Side Effects
  • Academic Work/Impact
  • Persistence of Symptoms

5. Please list any specific accommodations or services to address the functional limitations identified.

6. Do you anticipate any changes in the individual’s condition/medication? Yes/No Please explain.

7. Is the individual working with another physician or specialist to treat the condition? Yes/No Please explain and indicate who else if known.

8. Is there anything else you think we should know about the individual or their condition?

Please type or print clearly




License/Certification #



City/State/Zip Code:



Additional information can be submitted in a signed, typewritten letter on letterhead. Documentation must be returned to Disability Services staff at the specific Johns Hopkins School the student is attending.