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:MEDICALDISABILITY
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
SpecialistPhysician,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.
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signature
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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.
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)
DateofOnset(ifknown):______/______/______(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healthexpectedtodecline? YES NO
Ifyes,brieflydescribetheprognosis:
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
GlobalAssessmentofFunctioning(GAF)orWHO‐DAS Score: _____________
Other:
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 3 of 6
DISABILITYINFORMATION:(CheckallthatApply)
Student’sconditionand/ortreatmentsignificantlyaffectsfunctioningatcertaintimesoftheday:
Morning Afternoon Evening
Studentisrequiredtoattendregularlyscheduledmedicalappointments:
Onceaweek Twiceaweek Onceamonth
Other–Pleasespecify:
Studentmustavoidcontactwithoringestionofcertainsubstances
YES
NO
IfYes,pleasedescribe:
AIDS/SUPPORTSUSEDBYTHESTUDENT:(CheckallthatApply)
BloodPressureMonitor Glucometer
Epi‐Pen Inhaler
Other:____________________________________ Other:___________________________
CURRENTTREATMENT–Optional:(CheckallthatApply)
Physiotherapy OccupationalTherapy
Speech/LanguageTherapy ChiropracticTherapy
MassageTherapy 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
Page 4 of 6
OTASSESSMENTDECLARATION
ThefollowingRestrictions&Limitationssectionwascompletedbyaqualifiedoccupationaltherapist.In‐
depthsemi‐structuredinterviews,occupationalself‐assessments,chartreviews,performance‐based
measures,and/orconsultationwiththestudent’shealthcareteamwasusedincompletingthisassessment.
HCPName: Signature:
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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
PerformingActivitiesof
DailyLiving
Pain
EnergyLevel
PhysicalTolerance
Ambulation
ShortDistance
Ambulation‐Other
(e.g.unevenground)
ProlongedStanding
MaximumTime
______minutes
ProlongedSitting
MaximumTime
______minutes
StairClimbing
Lifting
MaximumWeight
_________lbs
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HCPInitial
Page 5 of 6
Activity
Mild Moderate Serious Severe Comment
RangeofMotion
Balance&Coordination
Reaching/Pushing/Pulling
RepetitiveActivity
Fine‐MotorDexterity
Speech
StressManagement
Concentration
Attention
Other
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
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:
SpecialistPhysician FamilyPhysician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
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