Referred to Disability Advisor:
Accessibility Services
Confidential Information Form
Date: _______________________
Last Name:
________________________________________________________________
First Name: ________________________________________________________________
Student Number: __________________________ Age: ______ Gender:
Permanent/Sessional
Address: _________ __________________________________________________________
City: ________________________________________ Postal Code: __________________
University of Toronto Email Address:
_____________________________________________________________@utoronto.ca
_________________________________________________________@mail.utoronto.ca
(Please confirm that your University of Toronto e-mail address ends in either @utoronto.ca or @mail.utoronto.ca)
Telephone:
Type:
Phone Number:
Session(s):
May we leave a
message?
Primary
 Home  Work (_______)
 Cell  Pager
________________________
 Sessional
 Permanent
Yes No
 Name & phone # only.
Alternate
 Home  Work (_______)
 Cell  Pager
________________________
 Sessional
 Permanent
Yes No
 Name & phone # only.
Have you used our services before?
Yes No If yes, who was your primary contact_____________________________,
and when were you here? ________________________________.
What is your current status at the University of Toronto?
 Part-Time Student (0.5 to 2.5 courses)
 Full-Time Student (3.0 or more courses)
 Special Student
 Visiting Student
Undergraduate students: How many credits have you earned?
 0 - 3.5
 4.0 - 8.5
 9.0 -13.5
 14 or more
PLEASE COMPLETE OTHER SIDE OF PAGE
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Access Programs
 Academic Bridging Program
Professional Faculty
 Applied Science &
Engineering
 Architecture
 Dentistry
 Forestry
 Law
 Medicine
 Music
 Nursing
 Occupational Therapy
 OISE/UT
 Pharmacy
 Faculty of Kinesiology
and Physical Education
 Physical Therapy
 Radiation Science
 Rotman
 Social Work
 Toronto School of
Theology
Degree:
 Transitional Year Program
 Special Student
________________________
St. George Campus
Undergraduate:
Arts & Science
 Innis College
 New College
 Saint Michael's College
 Trinity College
 University College
 Victoria University
 Woodsworth College
(See also Professional Faculty)
Degree:_________________
Program:________________
________________________
Graduate Studies:
Degree:
______________________
Program:
______________________
______________________
Stage in program:
 Course work
 Comprehensive
 Thesis
______________________
UTM/UTSC Undergraduate
You must first register with
Accessibility Services on your
home campus.
 Arts & Science UTM
 Arts & Science UTSC
______________________
International Student?
 Yes
 No
____________________
With which areas do you need assistance?
 Chronic Health Problem (e.g. epilepsy/MS/MD/IBD/Cancer)
 Mobility/Functional Disability (e.g. CP/Polio/RSI)
 Mental Health Condition (e.g. Depression/Bipolar/Anxiety
Disorder/OCD)
 Learning Disability or ADHD
 Brain Injury with Mobility Effect
 Concussion
 Sensory Disability (e.g. Hearing/Vision)
 Temporary (Please describe):
______________________
 Other (Please describe):
______________________
For Office Use Only:
Registration YES  NO 
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Entered in Database 
THE INFORMATION ON THIS FORM IS CONFIDENTIAL.
IF YOU NEED ASSISTANCE COMPLETING THIS FORM, PLEASE ASK AT THE FRONT DESK.
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ACCESSIBILITY SERVICES
Initial Questionnaire for Students with a Concussion
If you require assistance completing this form or need it in alternative format, please ask at the
front desk.
Please answer the following questions as completely as possible. The information you provide
will help us to develop an accommodation plan that meets your individual needs.
1. When did you receive your concussion?
(date)_________________________________
2. How did your concussion occur? (Please check one)






while playing/practicing sports
from a fall
from a motorcycle, car or bike accident
pedestrian accident
assault
other (please
specify)______________________________________________
3. Did you see a doctor, attend a clinic or visit a hospital after your injury?
 Yes
No
If yes, indicate who you saw:
_______________________________________________________________________
4. Were x-rays, CT of the brain or MRI of head undertaken? ________________________
5. Are you undergoing any treatment for your concussion?
 Yes
No
If yes, please describe:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Have you been referred to/seen a specialist?
If yes, please describe:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. Are you currently on medical leave by doctor recommendation?  Yes
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No
8. Have you missed class as a result of your injury?  Yes
9. Have you missed a test(s) as a result of your injury?  Yes
No
No
10. Have you spoken to your course coordinator/Registrar about your injury?  Yes
No
11. Since the date of your concussion, you may have experienced a number of physical
and/or cognitive symptoms. Please check all the boxes that apply as they relate to the LAST
WEEK only.

















headaches
sensitivity to light
neck pain
noise sensitivity
blurred vision
ringing/buzzing in ears
sleep disturbance – if yes:
 difficulty falling asleep
 difficulty staying asleep
 sleeping more/increased fatigue
reduced or lost sense of smell/taste
difficulty concentrating
difficulty paying attention
difficulty organizing work
difficulty remembering old information
difficulty reading
difficulty generating the right words
feeling “foggy”
more irritable
lowered mood/crying
12. Have you ever been told you have?
A learning disability
 Yes
Attention Deficit Disorder  Yes
A mental health condition  Yes
No
No
No
13. Have you had any prior concussions/head injuries?  Yes
No
14. If you answered yes to the above, please provide details of prior head injuries:
Date: ____________________________
Difficulties: _____________________________________________________________
______________________________________________________________________
______________________________________________________________________
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15. Are you currently registered at U of T?  Yes
No
16. What are your reasons for attending U of T? (academic/career goals)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
17. Have you ever been on academic probation or suspension?  Yes
18. Have you applied for OSAP?  Yes
If yes, are you OSAP eligible?  Yes
No
No
No
19. Do you have any additional comments or questions you would like to ask? Use the back
of the page if necessary.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Accessibility Services
Confidentiality and Consent to Share Information Agreement
In order to provide good service Accessibility Services wants students to have trust and confidence in how your
information will be used and shared. Staff employed by Accessibility Services regards information we learn about
students in interviews, personal communications and/or reports from other professionals as confidential as
required by law. We only convey information about the impact of your disability on your learning or your daily
needs while on campus with your permission. The level of information provided is on a need to know basis
meaning that only pertinent information relevant to the current request is shared. Your consent may be
withdrawn at any time by informing your disability counsellor in writing.
As required by law, Accessibility Services staff will reveal information when:




There is a suspicion of child abuse
A student poses a significant danger to themselves or others
A student reports sexual abuse by a health care professional
It is legally required, for example by subpoena, summons or court order
1. Please read and provide your written consent below:
 I give permission for my disability counselor to view my academic records on ROSI
 I understand that test/exam accommodations will be shared with Test and Exam Services at the Office of
Space Management.
2. In addition to necessary sharing of information among staff at Accessibility Services, I consent to the release
and sharing of information with the following:
Initial all that apply:
____ My Registrar at __________________ College
____ Professors in courses I am registered in at U of T
____ Student Health Services
____ Counselling and Psychological Services
____ Academic Progress Team
____ Other _____________________ please specify
Signature __________________________ Date ________________
Witness ___________________________ Date _________________
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UNIVERSITY OF TORONTO
ACCESSIBILITY SERVICES
Accessibility Services, University of Toronto
455 Spadina Avenue, 4th Floor, Suite 400, Toronto, Ontario, M5S 2G8
Tel: 416-978-8060
Fax: 416-978-5729
TTY: 416-978-1902
Documentation for Students with a Concussion
Accessibility Services provides support for students with documented disabilities, including
those with Temporary Disabilities. If you have sustained an injury that limits your ability to
attend to your academic responsibilities, you may be eligible to receive alternative
accommodations and support from Accessibility Services. In order to determine your eligibility,
contact our office as soon as possible and an appointment will be arranged. Accessibility
Services requires documentation to verify your injury, which you must bring to your first
appointment.
Please include the attached Medical Certificate completed by a physician, neurologist or
neurosurgeon, with the following information:





Date of Injury
Diagnosis/detailed description of injury
Treatment plan
Prescribed and over-the-counter medications with dosages
Anticipated length of recovery
Please also note:


If complications arise, or recovery takes longer than anticipated, students will be asked to
provide additional documentation.
When retrieving this information from the web, please obtain a University of Toronto
Student Medical Certificate from the Health Services website at www.utoronto.ca/health
If mailing or faxing (416-978-5729) documentation please direct it to the attention of
Accessibility Services.
For further information please visit the Accessibility Services web site, http://www.accessibility.utoronto.ca
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Please return completed form to:
Accessibility Services, University of Toronto
455 Spadina Avenue, 4th Floor, Suite 400, Toronto, Ontario, M5S 2G8
Tel: 416-978-8060
Fax: 416-978-5729
TTY: 416-978-1902
MEDICAL CERTIFICATE for CONCUSSION-RELATED ISSUES
This patient is requesting disability-related supports and accommodations while studying at the
University of Toronto. The student is required to provide the University with documentation
that is:
• provided by a licensed health-care professional, qualified in the appropriate specialty
• thorough enough to support the accommodations being considered or requested
Note: A diagnosis alone does not automatically mean disability-related accommodation is required
The provision of all reasonable accommodations and services is assessed based on the current impact
of the disability on academic performance. Generally this means that a diagnostic evaluation has been
completed within the last year.
CONFIDENTIALITY
Collection, use, and disclosure of this information is subject to all applicable privacy legislation
TO BE COMPLETED BY A REGULATED HEALTH PRACTITIONER – PLEASE PRINT CLEARLY
Patient’s Name: _______________________________________________________________
Patient’s University of Toronto Student Number: _____________________________________
Date of Birth: _____/_____/_____ (Year, Month, Day)
How long have you been treating this patient ?________________________________________
Last date of Clinical Assessment:___________________________________________________
STATEMENT OF DISABILITY
Please indicate the appropriate statement for this student in the current academic setting:

Permanent disability with on-going (chronic or episodic) symptoms (that will significantly impact the
student over the course of his/her academic career). This functional limitation is expected to
remain with you for the rest of your life.

Temporary with anticipated duration from ___/___/___ to ___/___/___ (Year, Month, Day) *If
unknown, please indicate reasonable duration for which s/he should be
accommodated/supported at this time (please specify number of weeks/months):
___________________________________________________________________
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DIAGNOSIS AND CONCURRENT CONDITIONS
Please provide a clear diagnostic statement; avoiding such terms as “suggests” or “is indicative of”. If the
diagnostic criteria are not present, this must be stated in the report.
Please note any multiple diagnoses or concurrent conditions.
Please note all applicable:
Primary:
___________________________________________________________________________________
Secondary:
_________________________________________________________________________________
Additional / Other:
___________________________________________________________________________________
MEDICATION(S)
N/A
Brand/Generic Name and dosage:
___________________________________________________________________________________
Brand/Generic Name and dosage:
___________________________________________________________________________________
Brand/Generic Name and dosage:
___________________________________________________________________________________
POTENTIAL SIDE EFFECTS OF MEDICATION(S) ON ACADEMIC PERFORMANCE:
___________________________________________________________________________________
Current treatment:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
IMPACTS ON ACADEMIC FUNCTIONING (please specify where possible)

Energy level (please specify impact e.g. fluctuating):
____________________________________________

Impact on Sleeping Cycles:
_______________________________________________________________

Ability to manage full work load:
____________________________________________________________

Recommendations for assignments/tests/exams:
______________________________________________
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COGNITIVE IMPACTS:
 Attention and Concentration
 Communication
 Information processing (written and verbal)
 Memory
 Organization and time management
 Social interactions
 Stress management
 Other/comments:
___________________________________________________________________________________
Does this individual require any adaptive equipment (lap top, voice recorder, furniture or seating in
class), software (Inspiration, Kurzweil) or other supports (massage, light box, counseling, FM system,
CCTV, hearing aid etc.) to achieve academic success?
Yes
No
Please be specific about what is required.
___________________________________________________________________________________
HEALTH CARE PRACTITIONER INFORMATION
Name of Health Practitioner (please PRINT):
Facility Name and address Note: If you do not have an office stamp please sign and attach your
letterhead – signatures on prescription pads will NOT be accepted
Please use office stamp
Specialty:
 Physician
o Family
o Neurologist
o Occupational Therapist
o Speech Pathologist
o Sports Medicine Specialist
o Psychiatrist
 Psychologist
 Other: ___________________________
Health Practitioner Signature:
License / Registration No.
Date
Telephone No.
Fax. No
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