Date:______________________

Name of Student:_______________________________________________________________

Dear Medical Professional:

The student whose name appears above has applied for services from the Disabled Students' Program (DSP) at UC Berkeley. In order for DSP to establish whether this student has a disability and to determine her/his eligibility for services, we will need your assessment and diagnosis of this student. A disability is defined as a physical or mental impairment that limits one or more major life activities such as those delineated below. You can fax or mail the form to us at the address in our letterhead. If you prefer, you can answer these questions in a signed and dated letter on your professional letterhead.

1. What is the diagnosis/impairment:

2. Date of diagnosis / impairment:_________________________________

3. Is the patient / student currently under your care?____________________

4. When did you last see the patient / student?:_____________________________

6. What are the specific functional limitations resulting from the impairment's impact on the major life activities identified above (i.e., unable to lift more than 10 lbs.; unable to keyboard more than 10 minutes out of 60 minutes)?

7. Please attach any other supporting information (e.g., neurological or psycho-educational test reports, etc.)

8. Medications, effects, and possible side-effects:

9. If student is currently undergoing treatment, please describe the treatment and how treatment may affect the student in a post-secondary setting.

10. Are the functional limitations permanent? If not, anticipated date of resolution?

Note:

Tests of cognition, information processing and academic achievement, which may not be part of the diagnostic process itself, may be needed by the Disabled Students' Program to determine appropriate academic accommodations and Services for a student with a mobility impairment or other impairment due to a medical condition.

 

______________________________________________________	_____________________
Signature of Medical Professional	Date

______________________________________________________	_____________________
Medical Professional's Name (printed)	License No.

 

_______________________________________________________ Address	_____________________ Telephone No.
_______________________________________________________	_____________________ Fax No.