Americans with Disabilities Act (ADA) Office
University of Delaware
413 Academy Street, Room 165
Newark, DE 19716
Phone: (302) 831- 4643
Fax: (302) 831-3261
TTY: (302) 831-4563
In order to evaluate how we can best meet your needs, we require specific information from both you and your examiner. Print out this form. See additional information below. You must complete the top portion of the form. Also, to facilitate the process, we need you to fill out and sign the Authorization to Receive Health Care Information below. This gives us permission to speak with your examiner if we have questions relating to his/her recommendation for accommodation(s). Your health care provider must complete the rest of this form, sign it, and return the completed packet to the above address.
Date:___________________________
Student Name (last, first, middle):
___________________________________________________________________
Date of Birth:_____________________________ Male ______ Female ________
New Freshman: _______ Returning Student:_______Transfer Student: ________
Current Campus Address (if applicable):__________________________________
Home Address:
___________________________________________________________________
___________________________________________________________________
Phone Number: ____________________________________
Email Address:_____________________________________
Authorization to Receive Information:
I authorize the University of Delaware, ADA Office, to receive information from the professional who fills out the Housing Documentation Form, and for him/her to discuss my condition(s) with the ADA Office if necessary.
Student Signature: __________________________________ Date:______________
Note: Housing Accommodations are provided on a case-by-case basis due to documented disabilities and medical conditions. To qualify as an ADA covered disability, the student must have a current condition that substantially limits a major life activity, and the accommodation must be necessary and reasonable. A diagnosis, in and of itself, does not automatically qualify for accommodations. To receive special housing consideration for medical conditions not covered by the ADA, this form must be completed, but accommodations are not guaranteed.
MEDICAL PROFESSIONAL SECTION
Please answer the following:
Student's Name:_______________________________________________________________
1. What is the current medical condition/diagnosis? _____________________________________________________________________________
_____________________________________________________________________________
Please check: Mild _____ Moderate _______ Severe _______
2. Expected duration of the condition:
Temporary_____ Permanent _____ Stable_____ Progressive_____
3. Describe the symptoms related to the medical condition that cause significant impairment to a major life activity (i.e. walking, breathing, sleeping, seeing, hearing, learning, socializing). Please relate it to housing accommodations requested:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. List the current medication(s) and adverse side effects.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Are there significant limitations to the student's functioning directly related to the prescribed medications?
Yes _____No_____
If yes, please describe.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. If medication treatments are successful, why are the accommodations necessary? ______________________________________________________________________________
______________________________________________________________________________
7. Please check below specific recommendations regarding housing accommodations for this student. Please note that the accommodations marked with an '*" are extremely limited and will only be considered for students meeting ADA criteria.
Housing accommodations are based upon the student's functional limitations and level of need.
* Year round Air Conditioning _____ Seasonal A/C _____ Single room _____
No extended housing _____ *Centrally located_____ Close to Dining _____
*Kitchen _____ Close to bathroom _____ *Wheelchair accessible _____
*In-room private bath _____ Limited Stair climbing _____, how many floors?_____
Further explanation for any of the above: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of Professional printed:_____________________________________________________
Signature of Professional:
__________________________________________________________Date:_______________
License #__________________________________________________State: ______________
Address:
______________________________________________________________________________
______________________________________________________________________________
Phone:_________________________________Fax: ___________________________________
The learning environment and residential living are central to the University of Delaware experience. Housing Assignment Services refers or forwards all medical, psychological or disability related requests for special housing to the Americans with Disabilities Act (ADA) Office. This information is kept confidential and is used to evaluate requests while evaluating each individual situation. To aid this process, requests should include:
In addition to the basic documentation about a medical condition, further recommendations from the Professional are welcome and will be given consideration in evaluating a request. Documentation usually must be updated annually unless the condition is such that it does not change. Please contact the ADA Office if you feel this applies to your situation.
Students requesting housing accommodations through the ADA Office must do so in addition to following all regular housing procedures by the established deadlines.
Requests to break housing contracts due to a medical, psychological or disability need to follow established procedures at Housing Assignment Services and provide documentation to the ADA Office. The documentation for release must include reasoning why moving the student to a different location on campus is not feasible, and the only accommodation is to move home or off campus.
Factors we consider when evaluating special housing requests