Documentation of Disability Form

Please note, this information will be considered by the Accommodations and Modifications Committee, which is comprised of UNC professionals representing faculty and program staff, Campus Health, Counseling and Psychological Services, Carolina Housing, Carolina Dining, the Learning Center, and Accessibility Resources and Service, in addition to any other documentation presented by the student.

This is not a mandatory form, but may be used by treating providers as a means of furnishing ARS with information and documentation to support the student's accommodations request(s).

Documentation must reflect that the condition substantially limits a major life activity or major bodily function. ARS utilizes flexibility and discretion in determining how recent documentation must be for consideration. Changing conditions and/or changes in how a condition impacts the individual may warrant more frequent updates. Generally, sufficient documentation includes: a psychological/psycho-educational evaluation or a letter from medical/mental health provider which includes the below numbered items.

1. Qualifications of Clinician/Provider:

  • Documentation must be typed on office or practice letterhead, dated and signed by a professional who is licensed or certified in the area for which the diagnosis is made. Name, title, and license/certification credentials must be stated and shall not be family members or others with a close personal relationship to the individual.

2. Diagnosis & History:

  • A diagnostic statement identifying the disability, including ICD or DSM classification along with any relevant personal, psychosocial, medical, developmental and/or educational history.

3. Description of Diagnostic Methodology:

  • A full description of the diagnostic methodology used, including data and measurements from appropriate evaluation instruments. The results obtained should draw a direct link to the diagnosis and the functional limitations of the disability. For cognitive disorders, evaluations should use adult norms.

4. Current Impact and Functional Limitations:

  • A clear description of the level of severity along with the current impact and functional limitations pertaining to the academic and/or residential settings. Information regarding if symptoms are constant or episodic, and the frequency and/or duration should be addressed.
  • Please also include information about any treatments, medications, and/or assistive devices/services currently prescribed or in use, should include a description of the mediating effects and potential side effects from such treatments.

5. Recommendations:

Recommendations are welcomed and considered, however ARS makes the ultimate determination on eligibility and reasonable academic adjustments necessary to provide equal access for participation in academic courses, programs and activities. Recommendations should be directly linked to the impact or functional limitations associated with the disability, or medication prescribed to control symptoms and include a clear rationale based on level of impairment.

Emotional Support Animal (ESA) accommodation requests:

  • As of November 2019, The Federal Trade Commission (FTC) has been asked to investigate websites that purport to provide documentation from a health care provider in support of requests for an ESA.  The websites in question offer documentation that is not reliable for purposes of determining whether an individual has a disability or disability-related need for an ESA because the website operators and health care professionals who consult with them lack the personal knowledge that is necessary to make such determinations. Also, please be aware ARS neither requires nor recognizes an ESA "license", "certificate" or "vest" as the basis for establishing the legitimacy of an ESA.
  • ACA members are specifically directed to the Emotional Support Animals - Human Animal Interventions in Counseling Interest Network Position Statement

Emotional Support Animal (ESA) documentation should include statements specific to:

  • ​The existing and continuing diagnostic and therapeutic relationship between the provider and client

  • A specific diagnosis of the condition, frequency of symptoms and severity and its impact on daily life activities and functional limitations

  • The methodology used to arrive at this diagnosis

  • A clear articulation of how the animal will mitigate these functional limitations

  • The observations, evaluations or means by which the provider determined that an ESA would be a reasonable accommodation

  • The provider’s confirmation that the ESA has been prescribed for treatment purposes and as part of a care or treatment plan and is necessary to help alleviate symptoms associated with your condition and how it will be critical in allowing you to use and enjoy university housing services. 

About you, the professional completing this form
Your client/patient (the student)
Professional contact with your client/patient
Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis - other