Evaluator Form – Residence Halls
University of Northern Iowa
Student Disability Services
The University of Northern Iowa, in compliance with the Americans with Disabilities Act (ADA), will provide window air-conditioners or single/special room assignments as a reasonable accommodation in select residence hall rooms of students with documented disabilities.
A residence hall is more than just a place to sleep and study. It is a place to relax, socialize, and partake in educational and recreational activities. Because this is a shared facility by hundreds of students participating in various residence hall activities throughout the day, living in a single room does not necessarily provide a
student with a quiet, distraction-free environment.
Air conditioners may be installed in select residence halls for those with chronic health conditions. Typically, allergies are not considered disabling; however, all accommodations are determined on a case-by-case basis.
Please note that administration of services will not occur until a completed Request for Services form and relevant documentation are on file at Student Disability Services (SDS).
PLEASE SEND THIS COMPLETED FORM AND DOCUMENTATION TO:
Student Disability Services
103 Student Health Center
University of Northern Iowa
Cedar Falls, IA 50614-0385
OR BY FAX TO:
319-273-7576
Please have your health care professional provide the following information. This form must be completed in full or it will be returned to you.
STUDENT NAME: STUDENT UNI ID#:
1. CREDENTIALS OF THE HEALTH CARE PROFESSIONAL
The best quality documentation is provided by a licensed or otherwise credentialed professional who has undergone appropriate and comprehensive training, has relevant experience, and has no personal relationship with the individual being evaluated.
Name: Title:
License or Certification:
Area of Specialization:
State in which Individual Practices:
2. DIAGNOSTIC STATEMENT IDENTIFYING THE CONDITION
Please include a clear diagnostic statement that describes how the condition was diagnosed and detail the typical progression or prognosis of the condition.
3. DESCRIPTION OF THE CURRENT FUNCTIONAL LIMITATIONS
What major life activities does this diagnosis impact within the residential environment?
seeing hearing caring for oneself
sleeping walking concentrating
breathing other:
What major bodily functions does this diagnosis impact within the residential environment?
respiratory digestive/bladder/bowel
functions of the immune system
circulatory other:
4. DESCRIPTION OF CURRENT AND PAST ACCOMMODATIONS, SERVICES AND/OR MEDICATIONS
Please include a description of current and past medications, auxiliary aids, assistive devices, support services and accommodations, including their effectiveness in ameliorating functional impacts of the condition.
5. RECOMMENDATIONS FOR ACCOMMODATIONS, ADAPTIVE DEVICES, ASSISTIVE SERVICES, COMPENSATORY STRATEGIES, AND/OR COLLATERAL SUPPORT SERVICES
Please provide your recommendation for residence hall accommodations and services for this individual.
air conditioner single room private bathroom
other:
Is the impact of the condition life threatening if the request is not met?
Yes No
Is the request an integral component of a treatment plan for the condition in question?
Yes No
What is the likely impact on academic performance if the request is not met?
Evaluating Professional’s Signature Date