Revised August 31
Verification of Personal Health Condition
Student Name: ________________________
Student Number: __________________________
Queen’s Email: ________________________
Phone Number: ___________________________
Section A: Authorization to Share Information - Completed by Student
I authorize the health care provider named below to complete this form in support of my request for academic
considerations. This form will be submitted to the designated individual(s) in my Faculty / School office and may be
shared with instructors or university personnel solely on a need to know basis.
Student Signature: _____________________________ Date: _____________________________
Section B: Verification of Personal Health Condition - Completed by the Health Care Provider
I certify that my assessment of this student and their level of impairments fall within my legislated scope of practice.
On the basis of my examination and applicable documented history, I verify that this student is experiencing a health
condition that is impairing their academic functioning. The following information is provided for Queen’s
University to use in determining academic considerations.
Section C: Health Care Provider’s Authorization - Completed by the Health Care Provider
Name: _______________________________ Profession / Position: ___________________________
Signature: _____________________________________ Date: ______________________________
Telephone # (if not Student Wellness Services): ___________________________________________
Address (indicate SWS if Student Wellness Services): _________________________________________
Impairment in Academic Functioning
Current impairment related to ongoing disability?
If yes, registered with Queen’s Student Accessibility Services (QSAS) for disability?
Yes No
If yes, do not complete this form. Send Letter of Accommodation to your instructor and contact QSAS, if needed.
Date of onset of impairment: _________________________
Anticipated duration of impairment (from date form completed):
< 1 wk 1 2 wks 2- 4 wks* 4 8 wks* 8- 12 wks*
If the student’s impairment is currently serious or severe, improvement to mild or moderate impairment is expected
within < 1 wk 1 2 wks 2- 4 wks 4 8 wks 8- 12 wks
*I would recommend academic advising to further understand academic options available? Yes No
Due to health condition might require:
Occasional absences from classes, labs, placement
Extra time on assignments and/or thesis/dissertation obligation to be negotiated with
Rescheduling or other consideration for timed evaluations (i.e., unable to write tests,
quizzes, midterms, final exams)
Consideration may also be required for: In class participation Group work
Other: ______________________________________________________
Unable to fulfill all or most academic obligations.
Anticipated date student can communicate with instructors to develop an academic plan:
Date _____________________________ OR N/A (i.e., able to communicate now)
This student will require academic accommodations in order to complete quizzes/tests/exams (e.g., additional time
during tests/exams, smaller classroom for writing tests/exams, washroom breaks, etc.) No Yes
If yes, the student understands they will be required to connect with Student Wellness Services to discuss a short-term
academic accommodation plan (613.533.6000 X 74842). ______(Student Initials or N/A).
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Revised August 31
Information about the Verification of Personal Health Condition Form
Students are responsible for providing this documentation to their Faculty/School Office and
contacting their individual instructors to negotiate academic considerations once
documentation is processed. The final decision regarding the academic considerations will be
made by the course instructor.
Where can students go for additional information and assistance?
If you require support while speaking with your instructor, you are welcome to contact your
Faculty/School Office for assistance. If you would prefer to speak with someone outside of your
Faculty/School, you can connect with Student Wellness Services. Please contact or 613.533.6000 X 74842.
Student Responsibilities
Disseminate this form see instructions for individual Faculties/Schools below. Follow the
instructions for the Faculty/School that is granting your degree.
Arts and Science (including students studying at BISC): Submit form to online portal.
Engineering & Applied Science: Submit forms at, for assistance
Nursing (BNSc): Submit form (email or hard copy) to Barb Bolton (Rm 113)
Education (B.Ed): Submit form (email or hard copy) to Alan Wilkinson (Rm A101a)
Commerce: Commerce: Submit a Request for Academic Consideration for Extenuating
Circumstances online on the Commerce Portal, under Academic Consideration. Submit
this form (via email) to No hard copy forms accepted.
Law: Submit form (email or hard copy) to Helen Connop (
Medicine: Submit form (email or hard copy) to the Learner Wellness Centre
Occupational Therapy: Submit form (email or hard copy) to your program assistant,
Laurie Kerr (
Physical Therapy: Submit form (email or hard copy) to Program Assistant Lindsey
Morey (
Bachelor of Health Sciences: Submit form electronically (email only) to the Bachelor of
Health Sciences Program Office (
Graduate Students: Submit form (email or hard copy) to your instructor(s) or supervisor
Instructor Responsibilities
Meet with student to negotiate academic considerations (i.e., deferral of tests/exams,
extensions on assignments, etc.)
Assess missed academic obligations and provide reasonable academic considerations, in good
faith, while maintaining essential academic requirements and standards
Assure students who are experiencing an extenuating circumstance that reasonable academic
consideration will be implemented, as appropriate, while ensuring essential academic
requirements are met