Queen’sStudentAccessibilityServices
Queen’sUniversity
CôtéSharpWellnessCentre,MitchellHall
69UnionStreet|Kingston,ON|K7L3N6
613‐533‐2506
https://www.queensu.ca/studentwellness/accessibility‐services/
DisabilityVerification
DisabilityCategory:ATTENTIONDISABILITY
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Psychiatrist,Psychologist,Neuropsychologist,FamilyPhysician
Pleaseprintclearlyinblackink
STUDENTINFORMATION:
LastName:_________________________ Preferred/GivenName:__________________________
DateofBirth:________________________ StudentNumber:______________________________
Queen’sNetID:___________________________ Phone:_______________________________________
FIELDWORK/PLACEMENTS:
Willyouberequiredtocompletefieldwork(placements/practicums/co‐op)?
YES NO
TypeofFieldwork:__________________________________________________________________________
DateFieldworkBegins:
DISCLOSUREOFDIAGNOSIS:
Note:YouareNOTrequiredtodiscloseyourmedicaldiagnosisinordertoreceiveaccommodationsandsupports.
However,QSASdoesrequireverificationofthenatureofyourdisabilityand,moreimportantly,informationabouthow
itimpactsyouatuniversity.QSASwillusethisinformationtorecommendappropriateaccommodationsandsupports
foryouatQueen’s.
CONFIDENTIALITY:
InformationprovidedtoQSASinthisform,includinganymedicaldiagnosis(es),iskeptstrictlyconfidential.Itisnot
sharedwithanyoneoutsideofQSAS,includingwithotheruniversitydepartments,withouttheexpressedandwritten
consentand/ordirectionofthestudent.
Doyouconsenttoyourmedicaldiagnosisbeingidentifiedonthisformand
communicatedtoQueen’sStudentAccessibilityServices?
YES
NO
RELEASEOFINFORMATION:
IherebyauthorizemyHealthCareProfessional(HCP),whoiscompletingandsigningthisform,toshareinformation
withQueen’sStudentAccessibilityServicesaboutmydisabilityanditsfunctionalimpacts.
StudentSignature: Date:
PersonalinformationiscollectedundertheauthorityoftheQueen’sUniversityRoyalCharter,1841(asamended)andwillbeusedtoprovidedisability‐
relatedservicesandaccommodationsforstudiesatuniversity.
Student’sInformedReleaseisdoneinaccordancewiththefollowingsectionsoftheFreedomofInformationandProtectionofPrivacyAct:41.(1)(a),
41.(1)(b),and41.(1)(c)allowingfortheuseofpersonalinformationandsections42.(1)(b),42(1)(c),and42(1)(d)allowingforthedisclosureofpersonal
information.
click to sign
signature
click to edit
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 2 of 6
HEALTHCAREPROFESSIONAL:
Queen’sUniversityisrelyingon,andappreciates,yourdetailedknowledgeofthisstudent’sdisability,especiallyhowits
limitationsorrestrictionsmayimpactontheirlearningatuniversity.Carefulconsiderationshouldbegiventothe
verificationofdisabilityanddegreeoffunctionallimitationinthesectionsbelow.
VERIFICATIONOFDISABILITY:
Ifthestudentconsentedabovetodisclosetheirmedicaldiagnosis,pleaseprovideacleardiagnostic
statement.IncludeDSM‐5Codeanddiagnosis.Avoidphrases‘suggests’,‘isindicativeof’,etc.NOTE:
Indicateanyco‐existingdiagnosesorconcurrentconditions,includingtheDSM‐5codewhereapplicable.
DURATION:
PERMANENT:Ongoing,willimpactthestudentoverthecourseoftheiracademiccareer,andis
expectedtoremainfortheirnaturallife
PERMANENT,EPISODIC:Periodsofgoodhealthinterruptedbyperiodsofillnessordisability,andis
expectedtoremainfortheirnaturallife
TEMPORARY: AnticipatedDuration ______/______(MM,YR)to ______/______(MM,YR)
PROVISIONAL:
Iamstillmonitoring/assessingthestudent.
Assessmentlikelytobecompletedby:______/______/______(DD,MM,YR)
NextClinicalAssessmentDate(ifapplicable):______/______/______(DD,MM,YR)
Ifdurationisunknown,pleaseindicateareasonabledurationforwhichthestudentshouldbe
accommodated:_____________________(numberofmonths)orwhichTERM(S):
FALL WINTER SPRING/SUMMER
PleaseNote:InterimAcademicAccommodationsmaybeprovidedduringtheassessmentperiod.Toextend
theseaccommodations,updateddocumentationmayberequiredforconditionsstillbeingassessed.
ASSESSMENTINFORMATION:
Howlonghasthestudentbeenyourpatient?
Seenforfirsttimetoday 1weekorless 6monthsorless
1yearorless Morethan1year
Willyoubemonitoring/treatingthisstudentwhiletheyareatQueen’s? YES NO
CLINICALASSESSMENTMETHODSUSED:(CheckallthatApply)
ClinicalAssessment Date(s):_____________________________________________________
GlobalAssessmentofFunctioning(GAF)orWHO‐DAS Score: _____________
PsychiatricEvaluation Date(s):_____________________________________________________
Neuropsychologicalorpsycho‐educationalassessment Date:__________________________
Pleaseprovideacopy,includingalistoftestscompletedandscores.
BehavioralObservations
Other:
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 3 of 6
DISABILITYINFORMATION:
Pleaseindicatelevelofseverity: Mild
Moderate Severe
DateofOnset:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:______/______/______ NextAssessment:______/______/______
Isthestudent’sfunctioningrestrictedatcertaintimesoftheday?Ifso,
pleasespecify:

Morning
Afternoon Evening
CURRENTTREATMENT–Optional:(CheckallthatApply)
Psychotherapy MassageTherapy
Grouptherapy OccupationalTherapy
Coaching Physiotherapy
Other: Other:
Isthestudentcurrentlytakingmedicationfortheirsymptoms?
YES
NO
Ifyes,pleasespecifyanysideeffectsthatimpactonthestudent’sfunctioning?

Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
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RESTRICTIONSANDLIMITATIONS:
NOTE:TheHealthCareProvidermustcompletethissectioninconsultationwiththestudent.Studentsshouldnotcompletethis
sectionindependentlywithoutinputfromtheirHealthCareProvider.
Pleasechecktheseverityofdisabilitybasedonthenumberandseverityofsymptoms/restrictions,andtheir
impactonthestudent’sfunctioninginauniversityacademicenvironment.Pleaseusethefollowingscale:
Mild: Noimpact,ormildimpact.Thestudentdoesnotrequireacademicaccommodation.
Moderate: Symptomsareprominent.Thestudentwillrequiresomeacademicaccommodation.
Serious:
Thestudenthasahighdegreeofimpairment.Symptoms/restrictionsmarkedlyinterfereswithacademic
functioning.Studentwillrequiresignificantacademicaccommodation.
Severe:
Symptoms/restrictionssoseverethatstudentisunabletofunctionatanylevelinauniversityacademic
environment,evenwithsignificantacademicaccommodation.
Symptoms/Restrictions Mild Moderate Serious Severe Comment
PHYSICAL:
Fatigue

ExcessMotorActivity

PoorImpulseControl

RiskTakingBehavior

S
LEEP:
Insomnia

PoorSleepHygiene

TroubleFallingAsleep

SleepApnea

THINKING:
RacingThoughts

DifficultyProcessing
Information

DifficultyConcentrating

DifficultyRemembering

Difficulty
Organizing/Planning

DifficultywithDivided
Attention


Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
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
Symptoms/Restrictions
Mild Moderate Serious Severe Comment
DifficultyManaging
InternalDistractions

DifficultyManaging
ExternalDistractions

DifficultywithSustained
Attention/Focus

CognitiveFatigue

SOCIO‐EMOTIONAL:
EasilyFrustrated

WeakEmotional
Regulation

DifficultyInteractingwith
Others

PoorLanguage
Pragmatics

DifficultyMaking
Decisions

LowMotivation

Problemswith
Procrastination

PoorTimeManagement

ACTIVITIES–Optional:
Usingthesamescaleabove,pleaseindicatethelevelofimpactofthestudent’sdisabilityandtheirassociated
symptoms/restrictionsonthefollowingactivitiesexpectedoftheminauniversityenvironment:
Activity
Mil
d
Moderate
S
erious
S
evere Comment
AttendingClass
TakingNotes
Reading
Writing
CompletingExams
DeliveringPresentations
MeetingAssignmentDeadlines

Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
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
Activity
Mild
Moderate Serious Severe Comment
ParticipatinginGroupActivities
Other

COURSELOAD:
Isthestudent’sconditionsufficientlystableatthistimetosustainparticipationin
regularuniversityacademicactivities?
YES
NO
Inyouropinion,isthisstudentabletomeetthedemandsofafullcourseload(15‐
20hoursofclass,lab,ortutorialmeetingsperweek,plus25‐30hoursofstudytime
perweek?
YES
NO
Ifno,pleaseestimatethemaximumamountoftimeinhoursperweekthatthestudentshouldbeableto
spendintheseactivities:_____________________________
AdditionalInformation(Pleaseusethisspacetoprovideanyotherinformationaboutthestudent’sdisabilityandtheir
functionallimitationsthatQueen’sshouldconsiderinsupportingthestudent)
HEALTHCAREPROFESSIONALINFORMATION:
Name:
(PleasePRINT)
FacilityNameandAddress(PleaseuseOfficialStamp)
(Note:Ifyoudonothaveanofficestamp,pleasesign,date,andattachapageofyourOfficeLetterhead)
Specialty:
PsychiatristNeuropsychologist
FamilyPhysician Psychologist
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
dsfsdf
click to sign
signature
click to edit
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