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:VISIONLOSS
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Ophthalmologist,Optometrist,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 5
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)
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visionexpectedtodecline?
YES
NO
Ifyes,brieflydescribetheanticipatedprogressionofvision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)
EyeExam Date(s):_____________________________________________________
VisualAcuityAssessment Date(s):_____________________________________________________
FunctionalVisionAssessment Date(s):_________________________________________________
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 3 of 5
GlobalAssessmentofFunctioning(GAF)orWHO‐DAS Score: _____________
Other:
DISABILITYINFORMATION:(CheckallthatApply)
VisualAcuity(bestcorrected): LeftEye __________ RightEye __________ Bilateral __________
Pleaseindicateseverityoflossinthefollowing:
VisualField Mild Moderate Severe
DepthPerception Mild Moderate Severe
ColourPerception Mild Moderate Severe
NightVision Mild Moderate Severe
DateofOnset:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:______/______/______ NextAssessment:______/______/______
Doesthestudenthaveaprintdisabilityrequiringalternative‐to‐printformats?
(i.e.,student’sabilitytoreadconventionalprintsignificantlyrestricted).
YES NO
AIDS/SUPPORTSUSEDBYTHESTUDENT:(CheckallthatApply)
Screen‐ReadingTechnology TextEnlargement(e.g.,magnifiers)
WhiteCane DarkorOtherSpecialGlasses
GPSforWayfinding GuideDogfortheBlind
CCTV Other:
Howdoesthestudentaccessprintedtext?
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
StudentrequiresOrientation&MobilityTrainingtotheuniversitycampus YES NO



Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 4 of 5
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
Balance&Coordination

Mobility/Navigation

NavigatingInformation
Systems 
SensitivitytoLight

DifficultyManaging
RegularStress
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
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 5 of 5
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:
OphthalmologistOptometrist
FamilyPhysician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
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signature
click to edit
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