Office Of Accessibility And Disability Services Verification Of A Disability Page 2
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1
23. Describe how this medical condition may affect this student academically and/or
physically.
4. List current medication(s) and adverse side effects.
5. What recommendations do you have regarding accommodations, e.g. extended time
for exams, adapted equipment, etc.?
Signature
Date
Provider Name and Degree:_________________________________________________
____Psychiatrist ____Physician ____Nurse Practitioner ____Physician’s Assistant
____Other:______________________________________________________________
License Number:________________________ State of Licensure:______________
Business Address:________________________________________________________
Phone:_________________________________ FAX:________________________
Return form to:
Coastal Carolina University
Office of Accessibility and Disability Services
P.O. Box 261954
Conway, SC 29528
FAX: (843) 349-5042
Phone: (843) 349-2503
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