Documentation of Disability

Students Name:

The above student has applied for disability services. To be considered for these services,
Luther College requires appropriate documentation. Please complete this form or, if you prefer,
use this format in a separate document. Please send documentation to the address below or
simply send it with the student.

1. Diagnostic statement identifying the disability.

2. Basis for diagnosis: summary of evaluation used, criteria for diagnosis, etc.

3. Description of current functional limitation caused by the disability.

4. Description of expected progression or stability of the disability.

5. List accommodations or interventions that have worked in the past and also, what has
not been successful.

6. Recommendations for accommodations, assistive services and/or collateral support

services for this student at Luther College.

Name of Provider Title

Address Phone

City/State/Zip Date

Student Academic Support Center 563.387.1270P 563-387-1411F sasc@luther.edu

Luther College 700 College Drive Decorah, Iowa 52101-1045 www.luther.edu