Documentation should be prepared on letterhead, typed, dated, and bear the signature of the evaluator. The documentation must be dated within one year of the semester for which the petition in being requested. Please ensure the documentation includes the name, title, contact information, and professional credentials as well as the information outlined below the medical reason for the petition.
PHYSICAL REASONS
- A statement of condition as a medical diagnosis.
- Include the date of diagnosis and the date of last contact with this student. Please indicate whether the condition is permanent or temporary (prognosis).
- A description of the procedures (e.g. clinical/diagnostic interview, rating scales, physical examination) that were used to assess/diagnose the medical condition.
- A description of the symptoms that meet the criteria for diagnosis with the approximate date of onset.
- A list of any medications or other treatments, including any possible medication/treatment side effects.
- Any additional medical information that may be relevant to the petition.
PSYCHOLOGICAL REASONS
- A statement of psychiatric, psychological, or learning impairment. Please provide a DSM diagnosis, if applicable.
- Date of diagnosis, dates of attendance, and date of last contact with this student
- A description of the symptoms that impacted the entire semester or individual courses
- A list of any medications/treatments the student is currently utilizing, including any possible side effects
- Any additional medical information that may be relevant to the petition.
DEATH OF IMMEDIATE FAMILY MEMBER
- Death Certificate
- Obituary
OTHER
- Police Report
- Statement from a victim advocate
- Medical documentation from an immediate family member’s medical provider