Please have your physician answer the following questions on your physician’s own letterhead, sign, and return to:

  • Trinity Washington University,
    Disability Student Services,
    125 Michigan Ave NE,
    Washington DC 20017

Questions for physician to answer:

  1. Physician’s Name/Credentials
  2. Physician’s Title/Specialty
  3. Student’s Name
  4. Student’s Date of Birth
  5. Name of the disability/ies
  6. Approximate date of diagnosis or onset
  7. Symptoms & barriers associated with disability/ies (i.e. chronic fatigue, inattentiveness)
  8. Prognosis or expected duration of symptoms
  9. Tests/Assessments used for diagnosis
  10. Current treatment regimen (Please include medications & possible side effects)
  11. If you anticipate that the disability/ies will interfere with the student academic participation, please specifically indicate
  12. Please attach any relevant supporting documentation (i.e. audiological report, psychoeducational assessment).

Please also include the physician’s address, phone number, fax number (if applicable) and email address.