Fillable Appendix 8 – Permanent Disability Programs Application (StudentAidBC)

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Appendix 8 – Permanent Disability Programs Application (StudentAidBC)

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Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
Appendix 8
REQUEST FOR PERMANENT DISABILITY PROGRAMS
AM I ELIGIBLE?
APPLICANTS MUST:
Have a permanent disability;
“Permanent disability” for the purposes of student financial aid, means “a functional limitation caused by a physical or mental
impairment that prevents a borrower from performing the daily activities necessary to participate fully in studies at a post-
secondary level and in the labour force and is expected to remain with the person for their expected life.”
Not all medical conditions are considered permanent disabilities for the purpose of StudentAid BC permanent disability program
funding.
Demonstrate financial need through the StudentAid BC (SABC) program for full-time or part-time studies;
Not be in default of a Canada student loan to be eligible for CSG-PD or CSG-PDSE;
Not be in default of a B.C. student loan to be eligible for the SBSD, BCAG or APSD; and
Not be ineligible for a Canada or B.C. student loan due to bankruptcy.
WHAT AM I ELIGIBLE FOR?
1. Grants and Bursaries
Canada Student Grant for Students with Permanent Disabilities (CSG-PD) – non-repayable grant of $2,000 per program year for
full-time or part-time students attending a designated public or private post-secondary institution.
B.C. Supplemental Bursary for Students with Disabilities (SBSD) – non-repayable grant of $800 per program year for full-time (40%
course load or greater) or $400 for part-time (20 to 39% course load) students studying at a post-secondary level at a designated
public or private institution.
B.C. Access Grant for Students with a Permanent Disability (BCAG) – non-repayable grant of up to $1,560 per program year to
reduce B.C. student loan debt for full-time students attending a designated public or private post-secondary institution.
2. Services and Equipment
Canada Student Grant for Services and Equipment for Students with Permanent Disabilities (CSG-PDSE) – non-repayable grant
of up to $20,000 per program year for full-time or part-time students for the purchase of exceptional education-related services
and/or equipment.
If you have exhausted your CSG-PDSE funding for the year, you may be eligible for the following program:
Assistance Program for Students with Permanent Disabilities (APSD) – non-repayable grant of up to $10,000 ($12,000 if attendant
care is required at school) per program year for the purchase of exceptional education-related services and/or equipment for
students attending a designated public or private post-secondary institution in B.C.
Non-post-secondary level students attending a designated public or private post-secondary school in British Columbia should contact
the Disability Coordinator at their post-secondary institution for additional information.
3. Learning Disability Assessment Reimbursement (CSG-PDSE)
This application allows you to apply for reimbursement of up to 75% of the cost of one psycho-educational assessment for a learning
disability (maximum of $1,700).
The assessment must clearly indicate that a learning disability (specific learning disorder) has been diagnosed which meets the
Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria. See Section 4.
HOW DO I DOCUMENT MY DISABILITY?
Verification of Permanent Disability (Section 4)
In order to be eligible for these Permanent Disability Programs, you must document your permanent disability. Section 4 of this
application must be completed by a qualified medical assessor in Canada.
Your physician or other qualified medical assessor must clearly indicate how your permanent disability impacts you on a daily basis in
an educational setting.
Fees that you may be charged to have this section completed are your responsibility and will not be reimbursed by StudentAid BC.
IF YOU HAVE PREVIOUSLY HAD YOUR PERMANENT DISABILITY STATUS APPROVED BY STUDENTAID BC,
YOU DO NOT NEED TO HAVE THIS SECTION COMPLETED UNLESS REQUESTED.
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
PROGRAM
REQUIRED DOCUMENTATION
CSG-PD
SBSD
BCAG
CSG-PDSE
Verification of Permanent Disability section or equivalent medical documentation
- Completed by a qualified medical assessor (i.e., physician, psychologist, nurse practitioner,
etc.) in Canada
- Current within 3 years
- Must indicate the daily impact on your ability to participate fully in your studies
Learning Disability documentation
- a copy of a current psycho-educational assessment
- psycho-educational assessment must have been completed within the past five years, or
the assessment must have been at age 18 or later.
Note: Medical documentation is usually only required once to establish your permanent disability
status. However, StudentAid BC reserves the right to request additional documentation at
any time it is deemed necessary to confirm or re-establish permanent disability status.
CSG-PDSE
(in addition to the
above documentation)
A copy of your registration form for your current course(s) applicable to the permanent disability
program funding you are requesting.
One cost estimate listing contact information, qualifications for the services offered, an
explanation or the services they will provide for you, for which course, the course dates, hourly
rate and how often per day/week.
Note: Family members can only provide services under exceptional circumstances and must be
pre-approved by StudentAid BC.
Learning Disability
Assessment
Reimbursement
(CSG-PDSE)
A receipt confirming payment. An invoice is not acceptable.
A copy of your current psycho-educational assessment must be attached.
Psycho-educational assessment must clearly indicate a diagnosis of a learning disability to
be eligible.
HOW DO I APPLY?
SECTION 1 – All students must complete.
SECTION 2 – All students must read and sign the declaration.
SECTION 3 – To be completed by the Disability Coordinator or designated school official, if applicable.
SECTION 4 – Verification of Permanent Disability. Have this section completed by a qualified medical assessor in Canada.
CONTACT YOUR DISABILITY COORDINATOR OR DESIGNATED SCHOOL OFFICIAL
FOR ASSISTANCE IN COMPLETING THIS APPLICATION
SUBMISSION INSTRUCTIONS
Upload your completed and signed Appendix 8 to your StudentAid BC Dashboard.
If you are applying for equipment only through the CSG-PDSE, contact:
Assistive Technology - British Columbia
108 – 1750 West 75
th
Avenue
Vancouver B.C. V6P 6G2
Phone: 604 264-8295
Fax: 604 263-2267
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
Appendix 8
REQUEST FOR PERMANENT DISABILITY PROGRAMS
SECTION 1: ALL STUDENTS MUST COMPLETE THIS SECTION
Student Last Name
SOCIAL INSURANCE NUMBER
-
Student First Name Initial
StudentAid BC Application Number
-
Mailing Address
Student Number
Apt/box/suite number
Personal Education Number (if known)
City/Town Province/State
Date of Birth
Year Month Day
-
-
Postal Code/Zip Code Area Code Telephone Number
-
-
Email Address
Date Classes Start Date Classes End
Year Month Day Year Month Day
-
-
to
-
-
Gender Male Female
Citizenship Status (Mark one box only)
Canadian Citizen
Protected Person
Permanent Resident
Name of School
Campus
REQUIREMENTS
YOUR PERMANENT DISABILITY STATUS MUST BE APPROVED BY
STUDENTAID BC AT LEAST 6 WEEKS BEFORE THE STUDY PERIOD END DATE.
MINISTRY USE ONLY
SECTION 2: DECLARATION – IMPORTANT DOCUMENT; YOU MUST READ, SIGN AND DATE
I am applying for assistance under any one or more of the permanent disability programs outlined in this appendix.
I UNDERSTAND THAT THIS APPENDIX FORMS PART OF MY APPLICATION FOR STUDENT FINANCIAL ASSISTANCE AND AS SUCH INCLUDES ALL TERMS AND CONDITIONS AS
STATED IN THE FULL TIME OR PART TIME STUDENTAID BC APPLICATION DECLARATIONS.
In addition to the terms and conditions stated in the Full Time or Part Time StudentAid BC Application Declarations, I also understand that;
1) If I receive money to pay for educational related specialized services through the Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities (CSG-PDSE) while
at a public or private post-secondary institution, or the Assistance Program for Students with Disabilities (APSD) program while at a private post-secondary institution, I will provide to
StudentAid BC, at the end of my study period, receipts showing that the funds were spent for their intended purpose, and will repay any unused funds to the British Columbia
Minister of Finance.
2) If I am attending a post-secondary institution in B.C., I will only request funds from the APSD program after I have exhausted all funds available through the CSG-PDSE.
3) I give permission to my physician or medical professional to disclose information directly related to my disability to the Ministry of Advanced Education, Skills and Training or Assistive
Technology British Columbia (The Board of Education of School District No. 39 (Vancouver) also known as Vancouver School Board) for the purposes or verifying or investigating information
pertaining to this application, and related documents, determining my eligibility for permanent disability funding.
4) I give permission to my school to disclose information to the Ministry of Advanced Education, Skills and Training or Assistive Technology British Columbia regarding my disability, access
requirements, academic standing, awards, living arrangements and financial status for the purposes of verifying or investigating information pertaining to this application and related
documents, determining my eligibility for permanent disability funding or determining whether I will be required to repay any funding I may receive.
5) If I am awarded a CSG-PDSE and/or a grant under the APSD, I authorize the institution I am attending or Assistive Technology British Columbia to cash the grant cheque(s) on my behalf
and apply the funds to retain a service worker and/or buy equipment and/or software on my behalf and/or apply the grant to the Learning Disability Assessment Bursary fund.
Signature of Applicant
Name
Date Signed (Year/Month/Day)
Collection and use of information. The information included in this form and authorized above is collected under Sections 26c and 26e of the Freedom of Information and Protection of Privacy Act, and
under the authority of the Canada Student Financial Assistance Act, R.S.C. 1994, Chapter C-28 and StudentAid BC. The information provided will be used to determine eligibility for a benefit through
StudentAid BC and for statistical and evaluation purposes. If you have any questions about the collection and use of this information, contact the Executive Director, StudentAid BC, Ministry of Advanced
Education, Skills and Training, PO Box 9173, Stn Prov Govt, Victoria B.C., V8W 9H7, telephone 1-800-561-1818 (toll-free in Canada/U.S.) or +1-778-309-4621 from outside North America.
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
SECTION 3: CSG-PDSE AND APSD (IF YOUR CSG-PDSE FUNDING IS EXHAUSTED) – SERVICES AND EQUIPMENT
To be reviewed and signed by Disability Coordinator or designated school official
LEARNING DISABILITY REIMBURSEMENT:
If you are submitting this application to apply for a Learning Disability Reimbursement, ensure that the following documentation is attached.
Psycho-educational report. Report must indicate a diagnosis of a Learning Disability to be eligible.
Original paid receipt (invoice is not acceptable)
How was the assessment paid for? Tick One:
School Paid (Learning Disability Assessment Bursary) Student Paid
EQUIPMENT:
All requests for equipment must be submitted to Assistive Technology British Columbia (AT-BC). An adaptive technology assessment will take
place to determine the appropriate equipment required to reduce any permanent disability related barriers that restrict the ability of the
student to perform the daily activities necessary to participate fully in studies at a post-secondary level.
Equipment is requested: Yes No
Please indicate your recommendations and/or rationale for specific equipment and/or software:
Ineligible equipment includes: ergonomic equipment/furniture, vehicle modifications, gas, insurance, physical alterations in the school or the
home, eyeglasses and hearing aids.
SERVICES:
Services will be/have been requested: Yes No
Services will only be approved if the service is directly related to the approved permanent disability.
Eligible services include: tutor, note-taker, reader, attendant care (while at school only), alternate formats, specialized transportation,
academic strategy sessions, interpreter/captionist.
Ineligible services include: proctor, photocopying, speech therapy, orientation services, other non-permanent disability school related costs.
Public Post-Secondary Institutions in B.C.: The Disability Coordinator must submit a Service Request to StudentAid BC by email and must retain
documentation at the school.
Private/Out-of-Province Institutions: The Disability Coordinator or appropriate official must submit a Service Request form to StudentAid BC
and include the required estimate(s) with the submission (www.StudentAidBC.ca).
Students must submit a completed Service Provider Receipt form at the end of each study period. Any unused funds must be repaid by
cheque or money order, payable to the Minister of Finance.
ASSISTANCE PROGRAM FOR STUDENTS WITH DISABILITIES (APSD) – PRIVATE SCHOOLS IN B.C. ONLY:
APSD funds may be available to students who are attending a designated school in B.C. AND who have exhausted the Canada Student Grant
for Services and Equipment. A service request must be submitted.
APSD is requested: Yes No
Disability Co-ordinator/School Official:
I certify the student is registered in the school indicated in Section 1 of this application and that the student requires the equipment and/or
services requested to reduce the barrier(s) caused by their permanent disability, so they can successfully complete their current educational
goals.
Signature of Disability Co-ordinator/School Official:
Date Signed (Year/Month/Day):
Name:
Telephone Number:
( )
Email Address:
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
SECTION 4: VERIFICATION OF PERMANENT DISABILITY
To be completed by a qualified medical assessor in Canada
PURPOSE OF THIS FORM:
This form will be used to determine eligibility for permanent disability grant funding through StudentAidBC. Eligibility for funding is based on
the daily functional impact(s) of the permanent disability on the person’s ability to participate in a post-secondary educational environment
and permanence of their disability. Forms that are incomplete or do not provide enough information will result in denial or delays of funding.
Please answer all questions: Birthdate:
Student Last Name
Student First Name Initial
Date of onset of Permanent Disability: (if applicable)
YYYY MM DD
-
-
How long has this person been in your care for these medical conditions? Provide Date:
YYYY MM DD
-
-
Permanence of Disability: (Choose ONE of the following statements)
The disability is permanent with ongoing (chronic or episodic) symptoms that will restrict the ability to perform the daily activities
necessary to fully participate in post-secondary studies and the permanent disability is expected to remain for their lifetime.
The person’s disability is temporary. Indicate the estimated recovery date:
YYYY MM DD
-
-
Severity and Prognosis:
Explain the severity and prognosis of the medical diagnosis:
Severity
Prognosis
Type of Disability (select all that apply):
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD). To be completed by Physician.
DSM Diagnosis
Cognitive Impairment (ex: Acquired Brain Injury, intellectual disability). To be completed by Physician or medical specialist.
DSM Diagnosis
Pervasive Developmental Disorder (Autism, Asperger’s, neurological). To be completed by Physician, Psychologist, or Psychiatrist.
DSM Diagnosis
Hearing Loss (You must provide a copy of your most recent audiology report). To be completed by Certified Audiologist.
Level of hearing loss in the better ear (select appropriate boxes)
Mild Uses aided hearing
Moderate Congenital
Severe Would benefit from amplification devices in an educational/vocational setting
Profound
Mobility/Agility Impairment (Spinal cord injury, spina bifida, arthritis, multiple sclerosis, soft tissue injury, etc.). To be completed by
Physician.
Diagnosis
Psychiatric or Psychological. To be completed by Clinical Psychologist, Psychiatrist or Physician.
DSM Diagnosis
YYYY MM DD
-
-
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
SECTION 4: VERIFICATION OF PERMANENT DISABILITY (CONTINUED)
Speech
Diagnosis
Visual (You must provide a copy of your most recent visual acuity report). To be completed by Ophthalmologist, Optometrist or Orthoptist.
A visual acuity of 6/21 (20/70) or less in the better eye after correction
A visual field or 20 degrees or less
Any progressive eye disease with a prognosis of becoming one of the above in the next two years
An uncorrectable vision problem or reduced visual stamina such that the applicant functions throughout the day as if his/her visual
acuity is limited to 6/21 or less
Other Permanent Disability / Chronic Health Impairment (Specify):
Learning Disability:
Qualifications of Assessor:
I am a registered psychologist/psychologist associate with an expertise in diagnosing learning disabilities.
I am a psychologist/psychologist associate in good standing with my provincial/territory in which I am recognized.
Documentation:
The assessment was completed on . Assessment must be less than five years old, or completed
at age 18 or older.
The assessment is complete, on official letterhead, includes the assessment date(s), the assessor’s name, title, professional
credentials, registration number, address, phone/fax number and is signed and dated.
Diagnosis:
The learning disability assessment clearly states a diagnosis of a learning disability meeting the DSM, and describes the level of
severity and the manner in which the disability significantly interferes with academic functioning (e.g. reading, writing, note taking,
memorizing, test taking, etc.).
The assessment contains recommendations for specific reasonable accommodations that would mitigate or reduce the impact of the
student’s permanent disability on their academic success/functioning.
The learning disability significantly interferes with academic achievement or activities of daily living that require reading,
mathematical or writing skills.
Office Use Only
YYYY MM DD
-
Rev. 2020/Jul/10 Appendix 8 Request for Permanent Disability Programs
StudentAid BC
SECTION 4: VERIFICATION OF PERMANENT DISABILITY (CONTINUED)
Disability Impacts on Daily Functioning (as it relates to educational setting):
Physical Impacts (Check all that apply. Indicate limitations, frequency, and level of severity.)
Standing Sitting Stair Climbing Ambulation (cane, wheelchair, walker, crutches)
Fatigue Handwriting Lifting/Carrying/Reaching Grasping/Gripping/Dexterity
Keyboarding Other____________________________________________________________________________________
Description of daily activities needed for post-secondary studies that are restricted as a result of the student’s disability
Cognitive and/or Behavioural Impacts (Check all that apply. Indicate limitations, frequency, and level of severity.)
Attention and Concentration Memory Information Processing (verbal and written)
Stress Management Social Interactions Organization and Time Management
Communication Fatigue Other ___________________________________
Description of daily activities needed for post-secondary studies that are restricted as a result of the student’s disability.
Medication
Is the person currently taking any prescription medications? Yes No
If yes, please indicate any side effects (alertness, concentration, nausea) that may affect participation in an educational environment:
Suggested Supports (must be related to permanent disability in an educational setting):
This person would benefit from taking a reduced course load.
Services: The person would benefit from specialized services such as tutoring, note-taking, sign language interpreting,
oral interpreting, classroom captioning, alternate formats in order to fully participate in post-secondary studies. Please specify:
Equipment: The person would benefit from assistive technology or equipment such as a computer or laptop, digital recorder,
FM system, braille reader, specialized software in order to fully participate in post-secondary studies. Please specify:
Name of Qualified Medical Assessor:
Registration Certificate No:
Specialty of Qualified Medical Assessor:
MEDICAL OFFICE STAMP
Signature:
REQUIRED
Date (Year/Month/Day):
Telephone No:
( )
Facsimile No:
( )
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Appendix 8 Permanent Disability Programs Application (StudentAidBC)

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Completed 15 January 2021

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