Disability Documentation Form

Students requesting academic accommodations through the Disabled Students Program (DSP) must provide documentation from a qualified provider. Under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act, a diagnosis alone does not automatically qualify a student for accommodations. DSP eligibility is determined by clinical data and the student's self-report demonstrating that the condition results in functional limitations that substantially limit major life activities in an academic setting.

Provider Guidelines for Completing Form: 

  • This form should be completed by a qualified professional with a treatment relationship with the student and must not be related to the student.
  •  Please answer all questions thoroughly and legibly, and ensure your signature (and supervising clinician, if applicable) is included to avoid processing delays.
  • Supplement this form with any evaluative reports to provide a comprehensive understanding of the student’s accommodation needs.
  • All information that you provide will be shared with the student.
  • Please return the completed form in any of the following ways: 
    • Via Student: Return the form to the student
    • Fax: 805-893-7127 
    • Mail: University of California, Disabled Students Program, 2120 Student Resource Building, Santa Barbara, CA 93106-3070.  
  • For questions, please call the DSP office at 805-893-2668 or email dsphelp@sa.ucsb.edu. Thank you for your assistance!

Please note: Questions marked with an asterisk (*) require an answer.

Section 1: Student Information

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Section 2: Diagnostic and Treatment Information

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Please provide the official diagnosis name(s) and initial diagnosis date (if known).

Please provide the official diagnosis name(s) and initial diagnosis date (if known).

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(e.g., number of Months/Years)

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Episodic/Flare-up Characteristics

If the student experiences episodes or flare-ups related to their condition, please answer the sub-questions below. If the student has a condition that is more constant or controlled, please skip to Section 3: Functional Limitations.

(e.g., once a day, once a week, twice a month, etc.) 

(e.g., 30 minutes, 5 hours, 1 day, etc.)

Section 3: Functional Limitations

Which, if any, of the major life activities listed below does the condition(s) impact? Please enter a number/symbol that reflects the severity of the impact using the rating scale below. 

Rating Scale: N/A = No Impact/Not Applicable | ? = Unknown | 1 = Mild Impact | 2 = Moderate Impact | 3 = Severe Impact

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Please explain

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Please explain

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(e.g., sensory sensitivities, prolonged sitting/standing limits, access to food/medication, etc.)

Section 4: Provider Certification & Signature

By electronically signing this form, you certify that you are an appropriately credentialed or licensed professional trained in the assessment and treatment of the diagnosis(es) described herein.
 

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If applicable:

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