Special Housing Requests

 

Dear Student,

 

In an effort to effectively respond to student requests for special housing modifications or accommodations, the University has created the Special Housing Request Committee.  The committee is made up of a group of JMU professionals representing Disability Services, the University Health Center and the Office of Residence Life.

 

In order to fully evaluate your request, the Special Housing Request Committee, will need documentation of your condition or disability.  Documentation should be current and comprehensive in light of the request and consist of an evaluation by an appropriate professional that describes the current functional impact of the condition or disability as it relates to the housing modification or accommodation requested. 

 

Documentation provided will be used by the Committee to evaluate your request.  The Committee will generate a list of potentially reasonable modifications or accommodations based on:

 

·        Information provided by the diagnosing professional

·        Potential effectiveness

·        Maximum level of integration

·        Potential for an undue financial or administrative burden

 

JMU reserves the right to request additional documentation if the information submitted appears to be outdated, inadequate in scope, or content, does not address the student's current level of functioning or substantiate their need for modifications or accommodations.

 

Students will be notified in writing of the Committee’s decision.

 

Deadlines:

A fully completed “Certification of Condition or Disability Form” must be received by the Special Housing Request Committee by the dates published in the One Book.  Requests received after the stated deadlines will be considered on an as available basis. Deadlines are set annually in keeping with other housing application deadlines, typically early March for returning students and late May for incoming Freshman.

 

The attached “Certification of Condition or Disability Form” has been developed to assist you in working with your diagnosing or treating professional to prepare the information needed to evaluate your request.  Please complete the attached form and return it to the Special Housing Request Committee.    A completed Health Record must also be on file in the University Health Center in order to fully evaluate your request.

 

Questions about the Special Housing Request process may be directed to the Special Housing Request Committee at SHRC@jmu.edu or by contacting the Office of Residence Life - Phone (540) 568-4663.

Special Housing Request Committee

James Madison University

MSC 1009 / Wilson Hall, Room 107

Harrisonburg, VA  22807

SHRC@jmu.edu

Special Housing Request

Certification of Medical Condition or Disability Form

PART 1 of 2

To Be Completed by the Student 

  1. The Special Housing Request Committee will be unable to consider any requests for housing modifications or accommodations until the requested information is received and a Health Record is on file in the Health Center.
  2. Fill out your name, address, Student ID / SSN, date of birth, in the space provided below.
  3. Have a qualified diagnosing/treating professional, who is familiar with your condition or disability complete the PART 2 of the form. You may need to explain the purpose of the form to your clinician. Note:  The diagnosing/treating professional should not be an immediate family member.
  4. Return this form, along with any supporting documentation to:

 

Special Housing Request Committee                

James Madison University                         or Fax forms to:  540-568-7099

MSC 1009 / Wilson Hall, Room 107

Harrisonburg, VA  22807

Please Print:

Student Name:           ____________________________________________________ 

Student ID#: __________________          Date of birth: ______________   Sex: ¨ M   ¨ F         

Address:        ___________________________________________         

City, State, Zip:  ___________________________________________      

Home Phone:            (____) ______ - ____________

E-Mail Address: _________________________

Current Resident Hall/PO Box:________________________________       

Current JMU/Local Phone:  ________________

Current Academic Level: ¨ Incoming Freshman  ¨ Incoming Transfer 

                                        ¨ Freshman  ¨ Sophomore  ¨ Junior  ¨ Senior

Do you have a Health Record on file in the University Health Center?  ¨ Yes   ¨ No

·  Describe Your Special Housing Request:   

 

This request is for housing in the   ¨ FALL /SPRING  ¨ SUMMER  of the year  _________.

¨ Modified equipment for deaf or hard of hearing persons, including TTY and fire alarms.

¨ Wheelchair accessible dorm

 

¨ Avoid stairs and/or must be on a lower level

¨ Wheelchair accessible shower

¨ Lowered closet rods

¨ Must have wheelchair access to elevator

 

¨ Wheelchair accessible furnishings (i.e. desk)

¨ Other:

 

 Explain how your request relates to your medical condition or disability.

 

 

 

To be complete, requests must include the student’s signature affirming agreement and clear responses to the questions above. Requests must be submitted in a timely fashion according to the deadlines for housing applications for each academic term.

 

As indicated by the signature below, the student submitting this request agrees that any information relevant to consideration of the request may be reviewed by appropriate University staff in evaluation and in any subsequent provision of accommodations.

 

 

 

Student’s signature

Date

Special Housing Request

Certification of Medical Condition or Disability Form - PART 2 of 2

 

To Be Completed by Diagnosing/Treating Professional
  1. Fill out your name, certification and contact information below.
  2. Provide information addressing the nine separate items listed below by filling out this form or providing a printed narrative on your official letterhead.
  3. Should the information requested below be contained in a current, comprehensive evaluation report – please attach a copy of the report to this form.
  4. Please note:  The patient should not be an immediate family member.

 

Qualified Diagnostic/Treating Professional Information:

Please type or print. Thank you.

Name: _____________________________________________________________________

 

Title:    _____________________________________________________________________

 

Certifications or Licensure: _____________________________________________________

 

Address:  ___________________________________________________________________

 

City, State, Zip:  ______________________________________________________________

 

Telephone Number:  _______________________Fax Number:  ________________________

 

Email:  _________________________________________________

 

 

 

Student Name:           ___________________________________________         

Student ID#: _______________          Date of Birth: ________________                Sex: ¨ M   ¨ F        

Address:        ___________________________________________         

City, State, Zip:  ___________________________________________      

Home Phone:            (____) ______ - ____________

 

 

 

Please Check The Most Appropriate Description For This Individual:

 

 

I, the undersigned diagnostic/treating professional, certify that the above named student:

 

Check One:    Meets the definition of a disability* as defined by the American’s with Disabilities Act &Section 504 of the Rehabilitation Act of 1973.

*Impairment that substantially limits a major life activity.

 

 Has a medical condition that is not a disability, but may warrant consideration for special housing modifications.

 

 Does not have a condition that would require the requested modification(s).

 

 

Please provide comprehensive answers to the following questions.

 

 

Student Name:       ___________________________________________ (physician’s page 2)

 

 

1.      Diagnostic statement identifying the condition or disability:

 

 

 

2.      Date of the most current diagnosis:         ____________________________

 

3.      Date of the original diagnosis:      ____________________________ 

 

4.      Description of the diagnostic tests, methods and/or criteria used to diagnose the condition or disability:

 

 

 

 

5.      Description of the current substantial functional impact of the condition or disability on a major life activity:

 

 

 

 

6.      Treatments, medications, and/or assistive devices/services currently prescribed or in use:

 

 

 

 

7.      Description of the expected progression or stability of the impact of the condition or disability over time, particularly the next 5 years.

 

 

 

8.      The condition or disability described above is:

 

Permanent/Chronic

Long term: 6-12 months

Short-term/Temporary: 6 months or less

            Expected duration:

 

9.   Please list any recommendations for housing modifications or accommodations and indicate how these modifications or accommodations would mitigate the substantial functional impact of the condition or disability. If relevant, you may also choose to address issues concerning impact on academic performance, social, and emotional well-being as well as the relationship of recommendations to the treatment plan and any negative impact that might result if accommodations are not provided. Use additional sheets as needed.

 

 

 

 

 

 

 

 

Signature of Diagnosing / Treating Professional

Date

 

 

FORM: 2006 SHR Verification of Condition or Disability Letter & Form.doc     Revised: Feb 2006