(b)2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Visual Impairments) <1/2>This medical certificate will be used in the course of assessing an application for special accommodations in
examinations/interviews for admission to Ritsumeikan Asia Pacific University. Thank you for your assistance inproviding as much detail as possible.
Name ofDate
Sex
ApplicantofMale / Female(Patient)
Birth
Address
Condition
diagnosed
Eyesight
Entering
information
on current
symptoms

Right eye:（ｘDCylDAx）

Left eye:（ｘDCylDAx）

・Please also explain impairments of visual function other than eyesight and visual field (nystagmus,near visual acuity, etc.) and any other relevant history or current symptoms.
Please be sure to state specifically why it is necessary to provide EACH of the special
accommodations requested by the applicant in their “Ritsumeikan Asia Pacific University SupportApplication.” (Please use the reverse side of this form if the space here is insufficient.)

Current
symptoms

I confirm that the above is my diagnosis.
Date:
Name of Medical Practitioner:

Medical Practitioner’s Place of Work:
Address/Telephone:[seal/signature](Field of specialization:)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Visual Impairments) <2/2>(Further information on current symptoms)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Hearing Impairments) <1/2>This medical certificate will be used in the course of assessing an application for special accommodations in
examinations/interviews for admission to Ritsumeikan Asia Pacific University. Thank you for your assistance inproviding as much detail as possible.
Name ofDate
Sex
ApplicantofMale / Female(Patient)
BirthAddress
Condition
diagnosed
Entering
informationin this form
Averagehearing
level
Hearing aid

・If the applicant uses a hearing aid, please state the type and model below.
・ Please attach the results of a speech perception test if the applicant has diminished speech
perception, even if the degree of impairment is mild.
Right ear:dB

Left ear:dB(method used:)Type:
Model:
Please be sure to state specifically why it is necessary to provide EACH of the special
accommodations requested by the applicant in their “Ritsumeikan Asia Pacific University SupportApplication.” (Please use the reverse side of this form if the space here is insufficient.)

Currentsymptoms

I confirm that the above is my diagnosis.
Date:
Name of Medical Practitioner:

Medical Practitioner’s Place of Work:
Address/Telephone:[seal/signature](Field of specialization:)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Hearing Impairments) <2/2>(Further information on current symptoms)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificatefor Special Accommodations (for Movement/ Nervous System Impairments) <1/2>This medical certificate will be used in the course of assessing an application for special accommodations in
examinations/interviews for admission to Ritsumeikan Asia Pacific University. Thank you for your assistance inproviding as much detail as possible.
Name ofDate
Sex
ApplicantofMale / Female(Patient)
BirthAddress(In the case of cerebral palsy, include physiological classification etc.; in the case of spinal cord
injury, include the level, etc.)
Condition
diagnosed

Date of first diagnosis or external injury:・Please include information on functional impairment of the trunk (especially capacity
to maintain a seated positing, reading/writing posture, etc.), functional impairment of
the upper body (writing capacity, etc.), concurrent conditions, and any other relevant
Instructhistory and current symptoms.
ions
・If the applicant is seeking an extension in examination time (1.3 times the standard time)or a separate examination room, please explain the reasons therefor. In the case of arequest for a separate examination room, if there is a particular requirement to use a
private room (for the applicant alone) please also explain the reason therefor.
Please be sure to state specifically why it is necessary to provide EACH of the special
accommodations requested by the applicant in their “Ritsumeikan Asia Pacific University SupportApplication.” (Please use the reverse side of this form if the space here is insufficient.)

Current
symptoms

I confirm that the above is my diagnosis.
Date:
Name of Medical Practitioner:

Medical Practitioner’s Place of Work:
Address/Telephone:[seal/signature](Field of specialization:)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Movement/ Nervous System Impairments) <2/2>(Further information on current symptoms)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Developmental Disabilities) <1/2>This medical certificate will be used in the course of assessing an application for special accommodations in
examinations/interviews for admission to Ritsumeikan Asia Pacific University. Thank you for your assistance inproviding as much detail as possible.
Name ofDate
Sex
ApplicantofMale / Female(Patient)
BirthAddress

Condition
diagnosed

Currentsymptoms

Psychological/cognitivetesting,behavioralassessments,etc.

Primarycondition(Autism, Asperger Syndrome, pervasive developmental disorder, learning disability,attention-deficit/hyperactivity disorder）

Concurrent
conditions
・If the applicant is seeking an extension in examination time (1.3 times the standardtime) or a separate examination room, please explain the reasons therefor. In the case
Instructof a request for a separate examination room, if there is a particular requirement toions
use a private room (for the applicant alone) please also explain the reason therefor.
・Please provide as much detail as possible on the need for special accommodations inrelation to reading, writing, etc.
Please be sure to state specifically why it is necessary to provide EACH of the special
accommodations requested by the applicant in their “Ritsumeikan Asia Pacific University
Support Application.” (Please use the reverse side of this form if the space here is insufficient.)

Instructions

・If providing information on multiple tests, please use the reverse side of this form.

Test name:
Test date:(in principle, must be within three years of the date of application)

I confirm that the above is my diagnosis.
Date:
Name of Medical Practitioner:

Medical Practitioner’s Place of Work:
Address/Telephone:[seal/signature](Field of specialization:)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Developmental Disabilities) <2/2>(Further information on current symptoms)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Other Health Conditions) <1/2>This medical certificate will be used in the course of assessing an application for special accommodations inexaminations/interviews for admission to Ritsumeikan Asia Pacific University. Thank you for your assistance inproviding as much detail as possible.
Name ofDate
Sex
ApplicantofMale / Female(Patient)
BirthAddress
Condition
diagnosed
・If the applicant is seeking an extension in examination time (1.3 times the standard time)or a separate examination room, please explain the reasons therefor. In the case of arequest for a separate examination room, if there is a particular requirement to use a
private room (for the applicant alone) please also explain the reason therefor.
Please be sure to state specifically why it is necessary to provide EACH of the special
accommodations requested by the applicant in their “Ritsumeikan Asia Pacific University SupportApplication.” (Please use the reverse side of this form if the space here is insufficient.)
Instructions

Current
symptoms

I confirm that the above is my diagnosis.
Date:
Name of Medical Practitioner:

Medical Practitioner’s Place of Work:
Address/Telephone:[seal/signature](Field of specialization:)

(b) 2024 Academic Year Ritsumeikan Asia Pacific University Medical Certificate
for Special Accommodations (for Other Health Conditions) <2/2>(Further information on current symptoms)