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:HEARINGDISABILITY
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Audiologist,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.NOTE:Indicateanyco‐existingdiagnosesorconcurrentconditions,ifapplicable.
DoesthestudenthaveaCentralAuditoryProcessingDisorder?
YES NO
DURATION:
PERMANENT:Ongoing,willimpactthestudentoverthecourseoftheiracademiccareer,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.
Isthestudent’shearingexpectedtodecline?
YES
NO
Ifyes,brieflydescribetheanticipatedprogressionofhearingloss:
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):_____________________________________________________
DiagnosticImaging/Tests MRI CT EEG
X‐ray
TuningForkTest Date(s):_______________________________
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 3 of 6
AudiometerTest* Date: _____________
Other:
*Pleaseattachacopyofthestudent’smostrecentAudiogram
DISABILITYINFORMATION:(CheckallthatApply)
Pleaseindicateseverityofhearingloss:
WithCorrectiveTechnology 
LeftEar Mild Moderate Severe
RightEar Mild Moderate Severe
WithoutCorrectiveTechnology 
LeftEar Mild Moderate Severe
RightEar Mild Moderate Severe
DateofOnset:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:______/______/______ NextAssessment:______/______/______
AIDS/SUPPORTSUSEDBYTHESTUDENT:(CheckallthatApply)
HearingAid(s) CochlearImplant(s)
FMSystem ASL/EnglishInterpretation
Real‐TimeCaptioning VideoCaptioning
Other: Other:
Howproficientisthestudentintheuseoftheabove‐refencedaids/supports?
Unfamiliar,needstraining/practice
Sufficientlyfamiliar,butadditionaltraining/practicewouldhelprealizefullbenefits
Proficient
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 4 of 6
RESTRICTIONSANDLIMITATIONS:
Note:TheHealthCareProvidermustcompletethissectioninconsultationwiththestudent.Students
shouldnotcompletethisformindependentlywithoutinputfromtheirHealthCareProvider.
Inthefollowingsection,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.S
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
Pain

RinginginEars(Tinnitus)

SensitivitytoLoudNoises

Fatigue

UnderstandingSpeechin
QuietSettings

UnderstandingSpeech
withBackgroundNoise

Following/Respondingto
Conversation

HearinginClassroom(no
mic)

HearinginClassroom
(withmic)

RecallingAuditory
Information

StressAboutNotHearing

MaintainAttention

ManagingDistraction

Other

Other

Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 5 of 6
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)
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
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 6 of 6
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:
AudiologistFamilyPhysician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
click to sign
signature
click to edit
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