understand
that housing staff may find it necessary to consult with IUB Accessible Educational Services and/or the IU Health
IUB Housing Medical Verification Form (MVF) for
Students Requesting Accommodations to the Housing Environment
This is for a housing accommodation. It is recommended this form is submitted when you complete your housing contract online.
• For incoming students for Fall: MVF and housing contract must be submitted before May 1 of that calendar year.
• For incoming students for Spring: MVF and housing contract must be submitted before December 1 of the prior calendar year.
Forms received after these dates may not be reviewed.
In order to evaluate how Indiana University Bloomington (IUB) can best meet your needs for special housing assignment requests, the
University requires specific diagnostic information from a licensed clinical professional or health care provider. This professional/health care
provider should be familiar with your history and functional limitations of your physical or psychological condition(s). You must complete
section one of the form. This information and your signature is required so that the appropriate and qualified member of the IUB staff
(Housing Operations and Assignments or Office of Student Life staff) has permission to speak with the professional/provider who completes
the information in section two to discuss your condition or resulting determination. The professional/health care provider must fill out
section two, sign, and return to you. You will then email the fully completed, PDF only, to [email protected], also noted below.
The completed packet is submitted in PDF form to the Housing Operations and Assignments Office from the student’s IU email account.
Failure to follow directions and complete both sections completely, will result in the form not being reviewed or result in significant delays.
The form will be processed, and the recommendations of the medical provider, along with the availability of space that will meet the
medical need will be considered.
Housing Operations and Assignments Office
801 N. Eagleson Ave, Room D101
Bloomington, IN 47405
[email protected]
If academic or campus wide accommodations are required, contact Accessible Educational Services at 812-855-7578 or [email protected]u.
If dining or allergen accommodations, in residential dining locations are required, contact the IU Dining Nutrition staff at nutrinfo@indiana.edu.
SECTION ONE – Student fills out section below. Please print or type.
I am requesting consideration for the following term:
Fall 2024 ☐ Spring 2025 ☐ Summer 2025 ☐
Student Name:
Last:
________________________
First:
__________________________________________________
Student ID #:
IU Email:
__________________________________________________
Birth Date:
Gender:
Male ☐ Female ☐ Another identity ☐
Home Address:
City:
______________
State:
_____
Zip:
___________
Cell Phone:
I am a(n):
Incoming First Year Student ☐ Transfer Student ☐
Returning to IUB ☐
Initial Each Statement and Sign: By my signature, I:
acknowledge that my medical condition may impact or limit my housing options, including roommate and location on
campus, so that housing can place me in an assignment that meets my needs. This medical request takes precedent over all
other room preferences submitted in my housing application.
Center about my request and needs and authorize them to do so in considering my request.
authorize IUB to receive information from the medical professional/provider below. I also authorize my provider to
discuss my condition(s) with the appropriate and qualified IUB personnel on an as needed basis.
Student Signature:
Date:
SECTION TWO – Medical/Health Care Provider fills out and signs section below. Please print or type.
Student’s Name:
DOB:
To determine special assignment consideration, Indiana University Bloomington (IUB) requires current and comprehensive
documentation of the student’s condition from a licensed clinical professional or health care provider familiar with the history and
functional limitations of the student’s condition(s). The provider completing this form cannot be a relative of the student. Items 1 thru
4 must be completed in full. If the space provided is not adequate, please attach a separate sheet of paper.
The provider may also attach a report providing additional related information to the student to provide to IU Housing.
Provider completes the sections below. Please respond to the following items in regards to the student named above.
1)
Date of Initial Contact with Student: Date of Last Office Visit with Student:
2)
What is the student’s medical condition/diagnosis (check all that apply)?
Date of Diagnosis
Diagnosis and Description of Symptoms
☐
Environmental
Allergies
☐
Vision Impairment
☐
Hearing Impairment
☐
Asthma
☐
Significant Mental
Health Concerns
☐
Mobility Limitation
☐
Other (specify)
3)
State the specific medical recommendations which effects the student’s daily living conditions. Include a rationale
as to why these housing needs are warranted based upon the student’s medical condition.
4)
Describe the current treatments, therapy plans, and any adaptive appliances or equipment used on a regular basis.
**The provider completing this form cannot be a relative of the student.**
Name:
________________________________________
Date:
___________________________
Signature of Provider:
________________________________________
Address:
___________________________
License Number:
________________________________________
City, State:
___________________________
Phone:
________________________________________
Zip code:
___________________________