Accommodated Housing Application: Provider Form

The health care provider need not use this specific form, but all the information requested here is necessary for the institution to consider the request for a housing accommodation

The student providing this form has indicated that you are their treating provider who has knowledge of their disability. This form must be completed by the provider of the student requesting a accessible housing accommodation. To ensure the provision of reasonable and appropriate services for students with disabilities at SUNY Polytechnic Institute, documentation must be provided by a qualified professional. Documentation must be current and provide comprehensive information regarding the student’s disability.

Please understand the submission of this form does not guarantee that the specific accommodation requested will be granted. The designated staff responsible for reviewing this request is looking to provide equal access to residential housing and will use the information on this form to determine 1) barriers to accessibility that the student would experience in a typical housing assignment, 2) how those barriers interfere with equal access, and 3) a link between how the requested housing accommodation would remove the barriers. Requests due solely to a preference or a potential benefit to the student are not considered disability-related and will not be considered.

Student Information

First Name

Preferred Name

Last Name

Birthdate

Provider Information

First Name of Provider

Last Name of Provider

Credentials title

Name of practice/place of employment

Country

Street

City

Region

Postal Code

Email address (we'll send confirmation and additional information)

Contact phone

Fax (if available)

Professional license #

State of licensure

Licensure expiration date

Accommodations Requested

What housing accommodation are you recommending (select all that apply)?

Housing Accommodation

Support Animal

Student-provider interaction and treatment information

What is the diagnosis/symptoms?

When did you first meet with the student regarding their diagnosis/symptoms?

When did you last interact with the student regarding their diagnosis/symptoms?

What is the current treatment plan, including any medications?

New York State Human Rights Law defines disability as a physical, mental, or medical impairment which prevents the exercise of a normal bodily function. Please explain how the student’s diagnosis meets this definition

Would you consider this condition mild, moderate, severe or episodic?

Is the condition stable, variable, or progressive?

What factors or environments could lead to an increase in the student's disability symptoms?

Please explain why the student will not be able to use and enjoy the residence hall without this accommodation and provide details regarding the connection between diagnosis/symptoms and the need for an accessible alternative housing assignment

Information about the Support Animal

Note: There may be some restrictions on the type of animal that can be approved for the residence hall

What specific symptoms is the student experiencing, and how will those symptoms be mitigated by the presence of the support animal? General assessments are typically insufficient. For example, a statement that "The animal alleviates anxiety" is too broad and does not explain how the animal may alleviate the symptoms of the student's disability.

What is the type/breed and gender of animal?

Is the animal house broke and/or trained to eliminate in a designated area?

What is the size of the crate/cage needed for containment?

Is there evidence that a support animal has helped this student in the past or currently? If not, why do you believe this may be effective for the student now?

Please address the impact on the student should the animal be permanently removed from the residence halls because of incompatible living, death, violation of policy, etc. and balance this impact against the benefit that you expect the animal to provide the student

Have you discussed the responsibilities associated with properly caring for an animal while engaged in typical college activities and residing in campus housing? Do you believe those responsibilities might exacerbate the student’s symptoms in any way (if you have not had this conversation with the student, we will discuss with the student at a later date)?

Supporting documentation (patient visit summaries, diagnostic reports/evaluations, etc) provides a more complete picture and helps us to support a student's specific needs. Do you want to upload documentation to this form?

Yes, I want to upload documentation now

No, I will plan to send to sas@sunypoly.edu

No, I will plan to fax to Student Accessibility Services at 315

No, I will plan to provide it to the student

Please upload relevant documents here

I confirm that I am the authorized provider completing this form. I understand that by completing and signing this form, I am certifying the accommodations are necessary and directly related to the symptoms of the identified disability and that due to the disability, the student is unable to live in a traditional residence hall placement without the accommodation.

By typing my name below, I acknowledge this as my electronic signature

Date

Accommodated Housing Application: Provider Form

Utica