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ACCESSIBLE LEARNING M C EDICAL INFORMATION REQUEST FORM

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Revised August 2020
ACCESSIBLE LEARNING
M
EDICAL INFORMATION REQUEST FORM
C
ONFIDENTIAL
Dear Licensed Medical Professional,
Please complete all sections of this form to support the student’s/patient’s registration with Accessible
Learning at Sheridan College for the purposes of receiving academic accommodations in accordance with
the Ontario Human Rights Code. To be eligible to complete this form you must be a Health Care
Professional under the jurisdiction of the Regulated Health Professions Act (1991) who, under the act, has
the right to determine the controlled act of diagnosis.
The form must confirm disability and indicate the functional limitations that the student/patient is likely to
experience in performing academic activities in a post-secondary setting. We rely on your detailed knowledge
of this student’s disability, including a description of the current functional impairments that may impact their
ability to meet essential course or program requirements so we may determine appropriate academic
accommodations.
If a patient/student wishes to access Federal and/or Provincial funding for assistive technology, diagnostic
services, and other academic supports, confirmation of a permanent disability is required; however, the
disability diagnosis does not need to be specified. Interim academic accommodations may also be
provided for students who are in the process of being assessed for a disability.
Certification of Health Care Professional
___________________________________________
First and last name (please print)
_________________________________________
Signature
Form completed on: _____/_____/_________
(day/month/year)
_________________________________________
Licence and Registration #
Address:
_____________________________________________
_____________________________________________
_____________________________________
________
___________________________________________
__
Business stamp or card:
Type of RHCP *Please note: a Learning Disability can only be diagnosed by a Psychologist or Psychological Associate.
☐ Audiologist ☐ Chiropractor ☐ Nurse Practitioner ☐ Ophthalmologist ☐ Optometrist
☐ Physician ☐ Psychiatrist ☐ Psychologist/Psychological Associate ☐ Physiotherapist
☐ Other____________________
Page 2 of 3
Patient/Student Information
_____________________________________________________
Patient’s/Student’s first and last name (please print)
Date of Birth: _____/_____/________
(day/month/year)
Statement of Disability
lease indicate (☒) the appropriate statement for this patient/student in the current academic
setting.
☐ Permanent disability with symptoms that are continuous or recurring/episodic.
☐ Temporary disability with anticipated/estimated duration from _____/_____/_____ to _____/_____/______.
(day/month/year) (day/month/year)
Patient/Student Consent for Disclosure of Diagnosis
Please note that disclosure of a diagnosis is NOT required in order to receive academic accommodations.
However, if the patient/student wishes to provide a diagnosis, please complete the information below with the
RHCP.
I, ________________________________________, hereby authorize the RHCP to disclose my diagnosis to
Accessible Learning at Sheridan College.
Patient’s/Student’s Signature: ____________________________________
Diagnosis: ________________________________________(as completed by the RHCP) RHCP initial: _______
Functional and Learning Needs Assessment
Impact of Medication
Please indicate impact of medication:
☐
Mild
☐
Moderate
☐
Severe
When is the medication
likely to impact academic functioning? (Check all that apply)
Morning
Afternoon Evening N/A
Daily Functional Limitations
Limited functioning at certain times of day (please specify): ☐ Morning
☐
Afternoon
☐
Evening
Additional Information Due to the impact of the patient’s/student’s disability, are any of the following recommended:
Reduced number of courses per semester? ☐Yes ☐No
Adaptive technology (e.g., speech-to-text, digital recorder)? ☐Yes ☐No
Accessible parking space required due to disability? ☐Yes ☐No
Page 3 of 3
Functional Impact: Symptoms of condition and/or medication(s) which may affect academic life.
Skills / Abilities
Mild
Severe
Comments
COGNITION and/or BEHAVIORAL
Attention / Concentration
Memory
Time Management
Organization
Information Processing
Comprehension
Communication (verbal or written expression)
Stress Management
Social Interactions
Emotional Self-regulation
PHYSICAL
Fatigue
Stair climbing
Lifting/carrying/reaching
Gripping/grasping/dexterity
Mobility
Ability to sit for a sustained period of time
Ability to stand for sustained periods
SENSORY
Vision
Hearing
Speech
Additional Comments or
Recommendations:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________
____________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Completed 7 December 2021

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