Accommodations Verification Form

This is a two-part form to be filled out by the student and their licensed health care provider. The form can be completed and submitted online, or downloaded here and returned to the College by mail.

Students: Complete the top section and click the orange text “Save and Continue” to generate a link that you can automatically email or give to your provider so they can complete and submit the remainder of the form.

Providers: Complete the provider portion section and click the gray SUBMIT button to finish the process.

Northland College provides reasonable accommodations to students with disabilities in accordance with applicable state and federal law. To determine eligibility for an accommodation, Northland College requires that the student be a qualified individual with a disability (i.e. have a physical or mental impairment that substantially limits one or more major life activities) and submit current documentation from an appropriate licensed professional or healthcare provider with relevant background and training. The submitted documentation must include the history, functional limitations, and expected duration of the student’s disability. In addition to the information requested below, please attach any supplemental information or documentation which will assist Northland College in assessing your limitation(s) and determining necessary accommodation(s). Please note that requests may be denied in the absence of adequate supporting documentation.
Are you the student or the provider?
- Student
- Provider
Providers, please scroll down to the Provider Authorization portion.
Student Authorization
To be completed by student.
Student Name*
First Last
Email*
I hereby authorize the licensed professional or medical provider referenced below to disclose protected medical information requested by this Disability Verification and Accommodation Request Form to Northland College. This medical information may be used by Northland College to make a proper determination of necessary accommodations. I also authorize my provider to discuss my health condition(s) with the appropriate Northland College personnel to make a proper determination of necessary accommodations. I understand that this authorization is voluntary and will remain effective for four years from the authorization date, unless I submit a revocation in writing to Northland College. I understand that a revocation is not effective to the extent that Northland College or the licensed professional or medical provider referenced below has already acted in reliance on my authorization. I understand that my treatment, payment, enrollment or eligibility for health benefits will not be conditioned on whether I sign this authorization. I also understand that Northland College, or the licensed professional or medical provider referenced below, may disclose this information and that the information may no longer be protected by federal or state law. Accordingly, Northland College and the licensed professional or medical provider referenced below are hereby released from legal responsibility or liability for the disclosure of the information requested by this form. My signature also indicates that the statements and documentation provided with this form have been completed by the appropriate licensed professional, healthcare provider, or their designee. I understand that providing false information is a violation of the Northland College Student Code of Conduct and may result in disciplinary action.
Provider Name*
First Last
Student Signature*

By entering my name, I am authorizing this release of information.
Date*
MM slash DD slash YYYY
Please click "Save and Continue" and enter your health care provider's email when prompted so they can complete and submit the remainder of the form. If you do not enter a valid email address, you will need to manually email or provide them with the link. If you do not get an automatically generated link and email confirmation, it means your form did not save and you need to try again.
Provider Authorization
Student assessment to be completed and submitted by the provider.
As the licensed professional or health care provider completing this form you must be familiar with the history and functional limitations of the student’s condition(s) and have the relevant background and training necessary to diagnose the student’s condition(s). You are not eligible to complete this form if you are related to the student. The documentation that supports the student’s request should reflect your own responses to the questions on this form.
Provider Name*
First Last
Title
Email*
State of Licensure*
License Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Fax
Signature*

By entering my name, I am indicating that the information on this form is factual to the best of my knowledge.
Date*
MM slash DD slash YYYY
Date of student’s first clinical visit with you*
Date of student’s last clinical visit with you*
Is the student currently under your care?*
- Yes
- No
State the diagnosed physical or mental health impairment(s). If applicable, list all DSM-V or ICD diagnoses (text and code):*
What information did you collect and/or review to arrive at your diagnosis?*
How does the disability currently impact the student?*
What is the expected duration of the student’s impairment(s)?*
Describe the severity and/or frequency of the student’s impairment (e.g., symptoms, functional limitations, or other substantial impact on ability to perform major life activities):
Identify any factors that may affect the severity of the impairment, and to what degree might the impairment be minimized by medication or other aids:*
Describe and explain the relevance of any medical and/or educational information that you are providing along with this form:*
List your recommendations for accommodations that are necessary to provide the student with equal access and opportunity to Northland College’s programs, activities, and services. Please provide an explanation or rationale for any recommendation with data from your medical evaluation, the student’s educational record, or other relevant sources (i.e. information supporting that the requested accommodation is necessary to assist the student in overcoming the functional limitations caused by the disability). If available in a separate report, please attach that report.*
File
Max. file size: 96 MB.
Describe the likely impact on the student if the accommodation request is not met.*
Describe any current or past accommodations and the effectiveness of those accommodations
Thank you for taking the time to complete this form. If we need additional information, we may contact you. All information is confidential and a copy of this form will be emailed to your for your records. For questions regarding completion of this form, contact the Office of Accommodations at 715-682-1340. Click the gray SUBMIT button to complete form. You will receive an email confirmation soon after submitting the form. If you do not receive an email confirmation, it means your form did not go through and you need to resubmit.

Save and Continue

Student Authorization

Provider Authorization