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:BRAININJURY
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Neurologist,Neuropsychologist,Psychiatrist,Psychologist,PsychologicalAssociate,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
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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.Avoidphrases‘suggests’,‘isindicativeof’,etc.NOTE:Indicateanyco‐existingdiagnosesor
concurrentconditions,indicating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: _____________
DiagnosticImaging/Tests MRI CT EEG
X‐ray
Neuropsychologicalorotherformalassessment. Date:__________________________
Pleaseprovideacopy,includingalistoftestscompletedandscores.
BehavioralObservations
Other:
g
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TYPEOFINJURY:
CONCUSSION DateofInjury:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:
______/______/______(DD,MM,YR)
NextAssessment:
______/______/______(DD,MM,YR)
Hasthestudenthadpreviousconcussions? YES NO
Ifyes,pleaseindicatehowmanypreviousconcussionsandtheirapproximatedate(s)ofoccurrence:
_________________________________________________________________________________________
BRAININJURY OTHER
Pleaseindicatetheseverityofinjury:
Mild Moderate Severe
DateofInjury:___________________________ DateofDiagnosis:_______________________________
CURRENTTREATMENT‐Optional:(CheckallthatApply)
ChiropracticTherapy MassageTherapy
NeuropsychologicalAssessment/Counselling OccupationalTherapy
OutpatientABITreatment Physiotherapy
Psychotherapy Speech/LanguageTherapy
Other:
Isthestudentcurrentlytakingmedicationfortheirsymptoms? YESNO
Ifyes,pleasespecifyanysideeffectsthatimpactonthestudent’sfunctioning?
_______________________
:
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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.
Inthefollowingsection,pleasechecktheseverityofdisabilitybasedonthenumberofandseverity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signifi
cantacademicaccommodation.
Severe:
Symptoms/restrictionssoseverethatstudentisunabletofunctionatanylevelinauniversityacademicenvironment,
evenwithsig
nificantacademicaccommodation.
Symptoms/Restrictions Mild Moderate Serious Severe Comment
PHYSICAL:
Dizziness
Fatigue
Headache
Nausea
SensitivitytoLight
SensitivitytoNoise
EyeFatigue/StrainAfter
____Minutes
RestrictedAbilitytoView
Screen
RestrictedAbilitytoRead
Print(Paper)
Visual/Perceptual
Problems
Vomiting
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HCPInitial
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S
ymptoms/Restrictions Mil
d
Moderate
S
erious
S
evere Comment
LEEP:
Drowsiness

SleepingLessthanUsual

SleepingMorethanUsual

TroubleFallingAsleep

THINKING:
FeelingMentallyFoggy

FeelingSlowedDown

DifficultyConcentrating

DifficultyRemembering

DifficultyProcessing
Information

DifficultyReasoningand
ThinkingRationally

Difficulty
Organizing/Planning

S
OCIO‐EMOTIONAL:
Irritability

Depressed/Sadness

Nervousness

DifficultyManaging
RegularStress

DifficultyManaging
InternalDistractions

DifficultyManaging
ExternalDistractions





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
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
ParticipatinginGroupActivities
Other
Other
CourseLoad:
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)

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HCPInitial
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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:
NeurologistNeuropsychologist
Psychiatrist Psychologist
PsychologicalAssociate
FamilyPhysician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax: Email:
click to sign
signature
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