Instructions.

Health Disability Provider Form

Tufts promotes an accessible college experience for all students, including those who are navigating disabilities. Specifically, the StAAR Center at Tufts is governed by the Americans with Disabilities’ Act, which defines disabilities as “a person with a disability who has a physical or mental impairment that substantially limits one or more major life activity.”

– ADAAA, 2008.

The StAAR Center employs an interactive process when determining if a student has a disability and if so, what accommodations are appropriate to ensure equal access to their Tufts experience. The student asking you to complete this form is in the process of seeking accommodations due to their disability.

Directions for the medical or mental health provider completing this form:

Use this form to provide information for the Tufts student who has requested an accommodation for their disability(ies). The information that you provide will be used to better understand the nature, severity and treatment plan for the student’s condition, the access barrier that they are navigating and the appropriateness of requested accommodations or services.
The information you provide must be current; in general, you must have seen the student within the last 6 to 12 months to meet this requirement. If you do not have sufficient information to respond to the questions on this form please inform the student directly.
Complete this form in its entirety. All information provided to The StAAR Center may be shared with the student, but is otherwise confidential per the Family Educational Rights and Privacy Act (FERPA).
The StAAR Center staff are mandated reporters, therefore will have to report explicit mentions of suicidal ideation, sexual misconduct, relationship violence, and harassment. If it is necessary to disclose this information, please request the student's consent, or communicate with the student that you have included the information on this form. This fosters respect, trust, and empowerment for the student during the reporting process. For questions, please contact the StAAR Center.
This form has 23 questions, and should take approximately 20-40 minutes to complete. All questions are required unless otherwise indicated. If you have questions regarding the information being requested in this form, please contact the StAAR Center via email at staarcenter@tufts.edu.

Text.

Student Information

Q1.

Name of student:

Q2. Student email address:

Text.

Current Healthcare Provider Information

Q3. Name of medical professional (include degree/specialty):

Q4. Contact Information (email/phone/address):

Q5. License #/State(s) licensed in:

Text.

Students' Diagnosis

Q6. Diagnosis (List all relevant diagnoses):

Q7. Based on your clinical experience with the student, does this diagnosis rise to the level of disability as defined by the ADA?

Yes
No
I don't have enough information/Unsure

Q8. Approximate onset of diagnosis:

Q9. Date of your last clinical contact with the student:

Q10. How did you arrive at this diagnosis (X-ray, lab work, interview w/ student, behavioral observations, testing, etc.)? Please list all:

Q11. Describe how the student’s disability creates a significant access barrier (or substantially limits their functional abilities) to their full and meaningful participation at Tufts. Please consider the higher education environment which includes but is not limited to, the classroom, dorm room, homework, dining halls, mobility, etc.

Q12. How frequently does the student’s disability create an access barrier to their Tufts experience?

Daily
1-3 times/week
1-3 times/month
1-3 times/year
None (symptoms are under control with medication and treatment)

Text.

COVID related disability/ accommodations:

*Note - If this is not applicable to your patient, skip this section.

Q13. For students with CDC-recognized COVID-high-risk conditions (e.g. chronic health conditions) who are seeking accommodations, please provide a holistic assessment of the student’s health risks for being on campus, considering: their unique medical profile, the latest information on vaccine efficacy, and the university’s safety practices.

Q14. For students without CDC-recognized high-risk conditions (e.g. mental health conditions): The description should include an explanation of how being on campus will disproportionately affect them compared to their peers such that specific accommodations (single rooms, remote participation, etc.) is the only viable option. This impact must go beyond the typical stress or nervousness.

Text.

Mitigation Plan (if applicable)

Q15.

Current treatment and medication regiment (including treating clinicians, frequency of treatment, medications, and side effects):

Q16. Severity of symptoms with treatment and/or medication regiment:

Mild
Moderate
Severe
N/A (Student is not engaged with treatment and/or medication regiment)

Q17. Will you be seeing the student again for their disability?

Yes
No

Q18. If yes, when is your next scheduled appointment?

Text.

Recommendation for Support at Tufts:

Q19. If you have recommendations on parameters or accommodations to support this student’s experience at Tufts University please share them here.

Questions we urge you to consider when making these recommendations are:

• Compared to their peers, what significant impacts will this student need to navigate?

• Describe how the accommodations you are recommending are in response to an access barrier and are not a preference for or on behalf of the student.

Q20. If these accommodations are denied, in your opinion, can the student still successfully navigate their Tufts experience?

Q21. Please provide any additional information that you feel will be useful in determining the nature and severity of the student’s disability, and any additional recommendations for resources the student will benefit from as they navigate their disability.

Q22. Please sign below. By doing so, you certify that you are the person listed as completing this form, and you verify that you are not related to the student by blood or marriage. You also confirm that all information you have provided is accurate and up-to-date.

Sign Here

clear

Q23. Date this form was completed:

Survey Completion
0%	Current Progress 0%	100%