Fillable Health Practitioner Report CONFIDENTIAL (AU Department of Education)

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Health Practitioner Report CONFIDENTIAL (AU Department of Education)

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  • 23 check-boxes
  • 20 other fields

Country of origin: AUSTRALIA
File type: PDF

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Access & Inclusion
Telephone: 02 6125 5036
Email: access.inclusion@anu.edu.au
Online: https://www.anu.edu.au/students/contacts/access-inclusion
Form: Health Practitioner Report
Page 1
Health Practitioner Report – CONFIDENTIAL
To assist the Australian National University (ANU) Access & Inclusion to arrange the most
appropriate support for this student we require detailed medical opinion on the impact of the
student’s health condition and their capacity to complete academic requirements. Thus Health
Practitioner Report form needs to be completed by a registered medical professional or health
care provider. This documentation will assist the ANU Access & Inclusion Office to assess, and
tailor, the student’s required adjustments and support.
IMPORTANT:
Personal information about students is protected under the Privacy Act 1988, Freedom of Information
Act 1982 (Commonwealth) and Australian National University Act 1991 (Commonwealth).
Ple
ase refer to https://policies.anu.edu.au/ppl/document/ANUP_000405 and
https://policies.anu.edu.au/ppl/document/ANUP_00
126
Student to complete
Name: University ID:
I hereby authorise
(practit
ioner name)
to release the following information to the Australian National University office of Access and Inclusion. I
also give consent for ANU Access and Inclusion to discuss my reasonable adjustment needs with my
practitioner:
Yes No
DOB: Phone Number
:
Signature:
Date:
(student signature)
Medical professional to complete
Health Practitioner’s Name:
Health Practitioner’s
Qualification(s):
Phone Number:
Provider Number:
Email Address:
Signature:
Date: Affix stamp:
click to sign
signature
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Access & Inclusion
Telephone: 02 6125 5036
Email: access.inclusion@anu.edu.au
Online: https://www.anu.edu.au/students/contacts/access-inclusion
Form: Health Practitioner Report
Page 2
This report is valid for the following period:
Months 1 year 2 years
Hearing
Medical
Neurological
Psychological
Writing
Learning
Vision
Mobility
Other
Stable
Fluctuating
Improving
Progressive
Permanent
Information regarding disability/condition
Medical diagnosis including year diagnosed (if known):
General description of medical condition(s) including management, referrals to other medical
professionals.
Description how the disability/condition impacts on the student’s ability to study:
(Please consider nature and level of impact relative to: mobility, reading, writing, concentration, memory,
attendance, participation, oral assessment, written examinations, written assignments, sitting for sustained
periods, lab work/practicum/field trips).
Access & Inclusion
Telephone: 02 6125 5036
Email: access.inclusion@anu.edu.au
Online: https://www.anu.edu.au/students/contacts/access-inclusion
Form: Health Practitioner Report
Page 3
If this is based on objectives evidence, please describe this evidence.
Recomme
ndations for Reasonable Adjustments
Please select appropriate field(s)
Examination Flexibility in deadline Equipment
Advoc
acy Mobility Other
Details: If possible, please specify adjustments or support which may be helpful as indicated above e.g.
breaks during exams.
Additional documentation
Please attach any additional documentation if available.
Note: W
ith a diagnosis of a Learning Disability a detailed assessment and report must be provided by a
suitably qualified mental health professional, such as Clinical, Educational, Neuropsychologist or a
Registered Psychologist or Psychiatrist.
Thank
you for your time in completing this report.
Submitting form
Please email completed form to access.inclusion@anu.edu.au
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Health Practitioner Report CONFIDENTIAL (AU Department of Education)

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Completed 15 December 2021

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