Un

niversity of Pittsb
burgh
Disaability Resou
urces and Services

140 Willliam Pitt Union

Pittsburgh, P
Pennsylvania 152600
4122-648-7890
Fax: 4412-624-3346
VP: 4112-536-5568

ESTA
ABLISHIING A DIISABILIITY
Individuaals seeking accommodat
a
tions from th
he Universityy of Pittsburrgh on the baasis of disabiility
are required to submiit documentaation to verify disabilityy and currentt level of imppairment undder
Section 504
5 of the Reehabilitation
n Act of 1973
3, the Ameriicans with D
Disabilities A
Act of 1990, and
the Amerricans with Disabilities
D
Amendment
A
Act of 20088.

1. Disab
bility Resou
urces and Seervices requ
uires curren
nt and comp
prehensive d
documentattion
in order to deterrmine reaso
onable accom
mmodationss. A disabiliity verificatiion form or a
document containing equivalent inform
mation mustt be submittted by each
h individual
requesting accom
mmodationss for the domain area m
most approp
priate for th
heir specificc
cond
dition (mediccal, psychia
atric, learnin
ng, attention
n).
2. The professiona
p
l documenting the cond
dition must be a qualiffied specialisst with
experrience or ex
xpertise in th
he domain for
f which h e/she is diaggnosing.
3. The professiona
p
l should sub
bmit any ad
dditional doccumentation that descrribes the
curreent impact of
o the condiition.
d
tion will be examined on
o an individ
dualized case-by-case iinquiry,
4. The documentat
speciifically look
king at the im
mpact of thee condition within the sspecific con
ntext of the
requested accom
mmodations.
5. Mediical recordss, case notess or medicall summariess used for other purposses will not
indep
pendently su
uffice as doccumentation.

Disability Resources and Services

140 William Pitt Union, 3959 Fifth Avenue Pittsburgh, PA 15260
Phone 412-648-7890 Fax 412-624-3346

Housing Accommodation Request Form

This request form must be completed in its entirety and medical documentation must be
submitted before a request will be given any consideration. All requests for
accommodations must be made in a reasonable time frame. Decisions will be made on a
first-come-first-serve basis.
Student Information
Student Name: _____________________________________________________________
(Last)
(First)
Birth Date: ____________________

Gender: Male _______ Female _______

Home Address: _________________________________________________________________

______________________________________________________________________________
Phone #: ________________________________________________
On Campus Address (If Assigned): _________________________________________________
______________________________________________________________________________
E-Mail Address: ___________________________________________
Requested Accommodation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

To determine eligibility for housing accommodations, the University of Pittsburgh requires current and
comprehensive information of the student's condition from the diagnosing physician or primary health care
provider. You must attach documentation from a qualified medical or other provider in support of your requested
accommodations(s). Documentation guidelines can be obtained at; http://www.drs.pitt.edu/documentation.html