Fillable Health Professional Report (James Cook University of North Queensland)

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Health Professional Report (James Cook University of North Queensland)

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The Health Professional Report (James Cook University of North Queensland) form is 2 pages long and contains:

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  • 7 check-boxes
  • 21 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for James Cook University of North Queensland

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1
Student Number:
Date:
Student
Name:
Last
First
James Cook University is committed to ensuring people with a disability/health condition are able
to participate to the fullest possible extent in the educational programs offered by the University
and all other aspects of University life.
AccessAbility Services provides services for students with
a
disability/health condition that aim to reduce the impact of their disability/health condition on
their study and enable equal access to learning.
If you have any questions please contact
Access
Ability in either Townsville or Cairns to speak to an AccessAbility Advisor.
Student consent to release/exchange information:
I
______________________________hereby give authority for ______________________________
Student’s name Health Professional’s name
to release information relating to my disability/
health condition to AccessAbility Services at James
Cook University
.
I also give authority for an AccessAbility Advisor to contact my health professional regarding my
disability/
health condition (optional).
Signature
: _________________________________________ Date: _________________________
Student’s Signature
Health Professional to complete:
Diagnosis or nature of disability/health condition:
Treatment (including any therapy, medication and side-effects):
Please indicate whether this condition is:
□
Permanent. If so, is the condition:
□ Fluctuating
□ Degenerative
□ Exacerbation
Next review date:
□ Temporary. If so, is the condition:
□ Fluctuating
□ Unchanging
□ Exacerbation
Expected duration:
Health Professional Report
Student Equity and Wellbeing
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2
AccessAbility Health Professional Report Feb 2017.docx CRICOS Provider Code 00117J
Impac
t of disability or health condition on study, placement and examinations at James
Cook University (e.g. concentration, memory, fatigue, motivation, nausea, mobility, visual
acuity, residual hearing):
Would you like to provide any comments for study arrangements or support? (e.g.
Assistive technology/equipment, alternative formatting, extra reading and/or writing time
considerations for assessments or examinations, ergonomic furniture, rest breaks,
medication, separate venue for exams.) Comments provided will be taken into
consideration in our assessment.
Practice Stamp:
Date: ____________________
Cairns
Phone: 07 4232 1150
Email: accessability.cns@jcu.edu.au
Professional’s Details:
Name: ______________________________
Profession: __________________________
Address: ____________________________
Phone: _____________________________
Email: ______________________________
Signature: ___________________________
Contact Details:
Townsville
Phone: 07 4781 4711
Email: accessability.tsv@jcu.edu.au Hours:
Monday – Friday 9am to 4pm Hours: Monday – Friday 9am to 4pm
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Health Professional Report (James Cook University of North Queensland)

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Completed 23 July 2020

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