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Verification of Temporary Disability(ies) - Form for Medical Providers

University promotes an accessible college experience for all students, including those who are navigating a temporary disability(ies). Tufts views temporary disabilities as those conditions that substantially impact a student’s ability to fully participate in the Tufts experience on a temporary (less than 6 months) basis. Temporary disabilities may include but are not limited to; broken bones, recovery from recent surgeries, concussions, etc.

In order for students to gain access to the appropriate accommodations for their situation, Tufts asks students to provide documentation verifying the diagnosed impairment or condition by a medical professional. Please use this form to provide information for a Tufts student who has requested an accommodation/ modification for a temporary disability. The information that you provide will be used to determine the nature, severity, anticipated duration and treatment plan for the student’s condition and the appropriateness of requested accommodations or services.

Make sure to 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). If you require a signed consent for release of information, please communicate that with the student prior to releasing their information.

If you have questions regarding the information being requested in this form, please contact:

The StAAR Center
Tufts University
617-627-4539
staarcenter@tufts.edu

Student Information:

1. Name of student:

2. Student email address:

3. Student phone number:

Current Healthcare Provider Information:

1. Name of medical professional:

2. Degree/Speciality:

3. Phone number:

4. Address:

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

Information about the Temporary Disability:

1. Diagnosis (List all relevant diagnoses):

2. Approximate onset of diagnosis:

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

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

5. Severity of symptoms with mitigation:

Mild
Moderate
Severe

6. Severity of symptoms without mitigation:

Mild
Moderate
Severe

7. Current treatment plan (please note any side effects due to medication):

8. Duration of current treatment plan (medication, OT, PT, therapy, etc.):

9. Prognosis of temporary condition:

Good
Fair
Poor

10. Please describe the substantially limiting symptoms which impacts this individual’s functional abilities (consider the higher education environment which includes but is not limited to the classroom, doing homework, the dorm room, the cafeteria, navigating campus, etc.).

11. Based on your clinical evaluation, what accommodations do you think this student will need to be an active member of the Tufts community while they navigate this disability?

12. Approximate duration of accommodations needed to support the student:

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

Yes
No

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

15. 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 other resources the student will benefit from as they navigate their disability.

16. IMPORTANT: In this form, did you disclose any of the following: suicidal ideation, sexual violence, relationship violence, and harassment?

Yes- As university officials, the StAAR Center staff are mandated reporters, therefore will have to report explicit mentions of suicidal ideation, sexual violence, 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 at 617-627-4539 or staarcenter@Tufts.edu
No

17. Please type your initials 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.

18. Date this form was completed: