Fillable Disability Resource Centre Information Package (Sauder School of Business)

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Disability Resource Centre Information Package (Sauder School of Business)

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  • 55 check-boxes
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Revised May 2020
Page 1 of 13
Disability Resource Centre
Information Package
Welco
me to the Disability Resource Centre at UBC Okanagan! We look forward to working with you.
We un
derstand and respect that your self-knowledge and experience is a relevant and important aspect to
determining the types of accommodations that will be most appropriate to you as you conduct your studies at
UBC Okanagan. The information you provide here along with your medical documentation will give us a good
foundation to start working together to determine the most reasonable accommodations to meet your
individual needs.
Deadlines
This
Information Package contains all the information you need to initiate the registration process at the
Disability Resource Centre. The registration process can take 2-4 weeks depending on the time of year, so
please submit your documents as soon as possible. Note: the last date that new registrations will be accepted
for the current term is two weeks before the start date of the formal final exam period for that term.
Checklist
□ Complete Self-Assessment & Information form (pages 3-4)
□ Read and sign Applicant Declaration and Disclosure Agreement (page 5)
□ Provide approved medical documentation (see Documentation Requirements on page 2)
□ Complete Verification of Disability form, if required (pages 7-13)
*Once your documentation has been reviewed you will be contacted for an
appointment.
Contact Us
The Disability Resource Centre
University Centre building, UNC 214
3272 University Way, Kelowna BC V1V 1V7
Telephone: (250) 807-8053
Fax: (855) 949-3705
Email: drc.questions@ubc.ca
Web: http://students.ok.ubc.ca/drc/welcome.html
Revised May 2020
Page 2 of 13
Di
sability Resource Centre
Documentation Requirements
To
register with the Disability Resource Centre, a student must provide documentation from a medical
professional qualified to diagnose and confirm the presence of the disability or medical condition for which
accommodations are sought. This documentation must describe the student’s disability-related academic
functional limitations in order to help the DRC assess and establish the student’s academic accommodations.
The type of documentation and the qualified professionals able to provide it depends on the nature of the
disability.
Dis
ability or
Medical Condition
Qualified Professionals
Required Documentation (the DRC requires
one of the following documents)
ADHD/ADD
• Specialized health professional (i.e.
registered psychologist, registered
psychological associate,
neuropsychologist, psychiatrist)
• Treating family physician
• DRC Verification of Disability Form
• Neuropsychological or Psychoeducational
Assessment
Autism spectrum
disorder
• Specialized health professional (i.e.
registered psychologist, psychiatrist)
• Treating family physician
• DRC Verification of Disability Form
• Psychoeducational Assessment
Anxiety disorders
• Specialized health professional (i.e.
registered psychologist, psychiatrist)
• Treating family physician
• DRC Verification of Disability Form
• Other formal medical assessment or report
Chronic medical
disabilities
• Specialized health professional
•
Treating family physician
• DRC Verification of Disability Form
Deaf /
Hard of hearing
• Audiologist • Audiology Assessment or Report
Learning disabilities
• Registered psychologist
• Psycho-Educational Assessment.
Note: Assessments completed after the age
of 18 must be less than 5 years old. If the
assessment was done before you were 18
years old, please consult with a DRC Advisor.
Mobility disabilities
• Specialized health professional
•
Treating family physician
• DRC Verification of Disability Form
Mental health
disabilities
• Specialized health professional (i.e.
psychiatrist, registered psychologist)
• Treating family physician
• DRC Verification of Disability Form
• Other formal medical assessment or report
Visual disabilities
• Specialized health professional (i.e.
ophthalmologist, optometrist)
• Optometry Report
Head injury /
Traumatic brain
injury
• Specialized health professional (i.e.
sports medicine physician, registered
neuropsychologist, registered
psychologist, neurologist)
•
Treating family physician
• DRC Verification of Disability Form
• Neuropsychological Assessment Report
Temporary medical
conditions
• Specialized health professional
• Treating family physician
• DRC Verification of Disability Form
Other bona fide
medical conditions
• Specialized health professional
•
Treating family physician
• DRC Verification of Disability Form
Revised May 2020
Page 3 of 13
Disa
bility Resource Centre
Self-Assessment & Information Form
Date:
_______________________________
Student Information
Last Name
First Name
Preferred Name
Current Address
Province
Postal Code
Telephone
Email
Date of Birth
(MM/DD/YYYY)
Do you currently have a student loan? If yes, please indicate which province.
Academic Information
Admission Status
□ Prospective Student
□ Current Student
Registration Status
□ Undergraduate
□ Graduate
□ Visiting/Go global/Exchange
Enrollment Status
□ Full Time
□ Part Time
□ Distance/Correspondence
Academic Program/Faculty/Major
UBC Student Number
Year of Study (e.g., first year)
Self-Assessment
Please briefly describe the nature of your disability and/or medical condition.
Revised May 2020
Page 4 of 13
How does it impact you in an educational setting?
Do
you have any secondary or multiple diagnoses, any medication side effects, or treatments you are currently
undergoing that may impact your functioning in an academic environment?
Hav
e you received academic accommodations or supports from a previous school? If yes, please describe:
Ple
ase list any assistive technologies that you use in your studies. (e.g., computer, speech-to-text software,
screen reading software, screen magnification).
Ple
ase provide a list of the accommodations you feel you will need at UBC Okanagan. These might include but
are not limited to extra time for exams, distraction reduced environment for exams, use of a computer, peer
note takers:
Revised May 2020
Page 5 of 13
Ap
plicant Declaration
In making this application to the Disability Resource Centre at UBC’s Okanagan campus to request services
and/or academic accommodations as a student with a disability I acknowledge that the above information
presents an accurate reflection of my needs based upon my knowledge and experience of my condition.
Pr
ivacy Notification: Your personal information is collected under the authority of section 26(c) of the Freedom
of Information and Protection of Privacy Act (FIPPA). This information will be used for determining your eligibility
for academic accommodations and if eligible, the appropriate accommodations. This information is kept
confidential and used only by the Disability Resource Centre to ensure the provision of services. Questions about
the collection of this information may be directed to Earllene Roberts, Manager of the Disability Resource
Centre, UBC Okanagan, 3272 University Way, Kelowna, BC V1V 1V7, 250-807-9263.
In matters of student appeals or complaints, the Disability Resource Centre is required to release student
information to the appropriate UBC officials.
Student Name: Date:
Disclosure Agreement *(sign one of the options below)
I have read the above statement and hereby consent to the release of information from my file by the
Disability Resource Centre to UBC faculty and staff only, as deemed necessary.
Stu
dent signature: _______________________________________ Date: ___________________
I do not consent to the release of information from my file by the Disability Resource Centre. I understand
that my refusal to consent may limit provision of service that can only be delivered in consultation with
officials of the University.
Stu
dent signature: _______________________________________ Date: ___________________
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Revised May 2020
Page 6 of 13
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Revised May 2020
Page 7 of 13
Disability Resource Centre
Verification of Disability Form
St
udent/Applicant Information
To be completed by student. Please print clearly.
Last Name
First Name
UBC Student Number
Address
City/Town
Province
Postal Code
Telephone
Email
Date of Birth (MM/DD/YYYY)
Student Authorization for Release of Medical Information
I, ______________________________________________, hereby authorize my physician to provide the
information contained on this form to the Disability Resource Centre at UBC Okanagan, and if required to supply
additional information relating to the provision of my academic accommodations and disability-related services.
I also authorize the Disability Resource Centre to contact the physician to discuss the provision of
accommodations.
Pr
ivacy Notification: Your personal information is collected under the authority of section 26(c) of the Freedom
of Information and Protection of Privacy Act (FIPPA). This information will be used for determining your eligibility
for academic accommodations and if eligible, the appropriate accommodations. This information is kept
confidential and used only by the Disability Resource Centre to ensure the provision of services. Questions about
the collection of this information may be directed to Earllene Roberts, Manager of the Disability Resource
Centre, UBC Okanagan, 3272 University Way, Kelowna, BC V1V 1V7, 250-807-9263.
Student signature Date
Witness Name (please print)
Witness Signature Date
Please have your physician complete the following pages (8-12) of this
Verification of Disability Form and fax directly to:
855-949-3705
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Revised May 2020
Page 8 of 13
Disability Resource Centre
Verification of Disability Form
This applicant is requesting disability-related supports and accommodations while studying at the University of
British Columbia Okanagan. The student is required to provide documentation that is:
Issu
ed by a licensed health care professional, unrelated by birth or marriage, who is qualified in the
appropriate specialty and qualified to diagnose the disability or condition for which accommodations are
being sought.
Be sufficiently comprehensive to establish clear evidence of the substantial impact on the student’s
functioning in an academic setting.
Be sufficient to establish a direct link between the underlying impairment and the requested
accommodation(s).
No
te: A diagnosis alone does not automatically mean that a disability-related accommodation is required.
Th
e provision of all reasonable accommodations and services is assessed based on the current impact of the
disability on academic performance. Generally this means that a diagnostic evaluation has been completed
within the last year.
The
following pages are to be completed by a physician or other regulated health care practitioner.
Please answer all questions. Please print clearly.
Student/Applicant Information
Last Name
First Name
Date of Birth (MM/DD/YYYY)
Date of onset of permanent disability or medical condition.
How long has this person been in your care for these
medical conditions? (please provide date)
Or, Is this your first time seeing/assessing this person?
□ Yes
□ No
__________________________________ ( MM/DD/YY) Date form being completed
Pe
rmanence of Disability
□ This 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 disability is temporary. Indicate the estimated recovery date (MM/DD/YYYY):
Revised May 2020
Page 9 of 13
Type of Disability
Select all that apply.
□ Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
DSM Diagnosis
Date of Diagnosis (MM/DD/YY) ______________Diagnosed by?___________________________________
□ Cognitive Impairment (e.g., acquired brain injury, intellectual disability)
DSM Diagnosis
Date of Diagnosis (MM/DD/YY)______________Diagnosed by?_____________________________________
Pervasive Developmental Disorder (Autism, Asperger’s, neurological)
DSM Diagnosis
Date of Diagnosis (MM/DD/YY) _____________Diagnosed by?_____________________________________
□ Hearing (Must provide a copy of most recent audiology report). Level of hearing loss in better ear:
□ Mild
□ Moderate
□ Severe
□ Profound
□ Uses aided hearing
□ Congenital
□ Would benefit from amplification
devices in an educational/vocational
setting
□ Mobility/Agility Impairment
(e.g., spinal cord injury, spina bifida, arthritis, multiple sclerosis, soft tissue injury)
Diagnosis
Date of Diagnosis (MM/DD/YY) __Diagnosed by?______________________________________
□ Psychiatric or Psychological
DSM Diagnosis
Who made the diagnosis? __________________________________________________________________
Date of Diagnosis (MM/DD/YY)
□ Speech
Diagnosis
Date of Diagnosis (MM/DD/YY) Diagnosed by?________________________________________
□ Visual (Must provide a copy of most recent visual acuity report).
□ A visual acuity of 6/21 (20/70) or less in the better eye after correction
□ A visual field of 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 the visual acuity is limited to 6/21 or less
Date of Diagnosis (MM/DD/YY) Diagnosed by?________________________________________
Revised May 2020
Page 10 of 13
□ Ot
her Permanent Disability / Chronic Health Impairment (specify):
Date of Diagnosis (MM/DD/YY) Diagnosed by?_________________________________
□ Learning Disability
□ Qualifications of Assessor: I am a registered psychologist/psychologist associate with an expertise in
diagnosing learning disabilities.
□ Documentation: The assessment was completed on (MM/DD/YYYY): .
Assessment must be less than 3 years old, or completed at age 18 or older and less than 5 years old.
□ Diagnosis: The learning disability assessment clearly states a diagnosis of a learning disability
meeting the Diagnostic and Statistical Manual for Mental Illness (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.)
A copy of the full psycho-educational assessment report is required for accommodations pertaining to a
specific learning disability. Please enclose a copy of the report with this document.
Severity and Prognosis
Explain the severity and prognosis of each medical diagnosis:
Severity
Prognosis
Revised May 2020
Page 11 of 13
Impact of Disability
Life / Activity Impacts
Mild
Impact
Moderate
Impact
Severe
Impact
Uncertain
Concentration
Memory
Sleep
Eating
Social Interactions
Self-Care
Managing Internal Distractions
Managing External Distractions
Timely Completion of Tasks
Regular and Timely Attendance
Making and Keeping Appointments
Stress Management
Organization
Physical Impacts
Fatigue
Standing
Sitting
Stair Climbing
Ambulation (cane, wheelchair, walker, crutches)
Grasping / Gripping / Dexterity
Academic Impacts
Writing
Notetaking
Examinations / Evaluative Situations
Keyboarding
Information processing (verbal and written)
Revised May 2020
Page 12 of 13
Medications
Is the student currently taking any prescription medications? □ Yes □ No
Please describe any side effects that may affect participation in an educational environment.
Do symptoms/limitations persist even with medications? If yes, please describe.
Suggested Supports
□ This person would benefit from taking a reduced course load. Maximum course load recommended:
□ 60%
□ 40%
□ Other
□ This person would benefit from specialized services such as tutoring, note-taking, sign language
interpreting, oral interpreting, classroom captioning, alternate format textbooks, etc. in order to fully
participate in post-secondary studies. Please specify:
□ This person would benefit from assistive technology or equipment such as a computer or laptop, digital
recorder, FM system, braille reader, specialized software, etc. in order to fully participate in post-secondary
studies. Please specify:
□ This person would benefit from on-campus housing (accessibility or priority placement). Please specify why:
□ This person would benefit from a disability parking pass. Please specify why:
□ This person would benefit from assistance with physical accessibility on campus (e.g., classrooms, labs,
library, crosswalks, curbs, etc.). Please specify why:
Revised May 2020
Page 13 of 13
Medical Assessor Information
Full Name
Telephone
Fax
Specialty (Please indicate all that apply)
□ Au
diologist
□ Neurologist
□ Ophthalmologist
□ Family Physician
□ Ps
ychiatrist
□ Registered Psychologist
□ Other (please specify)
__________________________________________
Address
City/Town
Province
Postal Code
Signature
Date (MM/DD/YY)
Official Stamp of Facility
Registration Certificate or License Number
Thank you for taking the time to complete this fo
rm. This information will facilitate the supports requested by
the applicant while s/he is a student at the University of British Columbia Okanagan. If you have any questions
or concerns, please contact Earllene Roberts, Manager of the Disability Resource Centre,
UBC Okanagan, 3272 University Way, Kelowna, BC V1V 1V7, 250-807-9263.
Please fax this completed Verification of Disability Form directly to 855-949-3705.
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Disability Resource Centre Information Package (Sauder School of Business)

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