Please complete, sign, and date Section 1, then provide this form to your health care provider for completion.
Please complete Sections 2 and 3. Remember to sign and date the form in Section 3.
When completed, please submit to:
Queen’s Student Accessibility Services
Queen’s University
La Salle Building, First Floor
146 Stuart Street
Kingston, ON, K7L 3N6
Tel: 613-533-6467
Fax: 613-533-6284
Email: accessibility.services@queensu.ca
Website: queensu.ca/sws/accessibilityservices
Queen’s is committed to an inclusive campus community with accessible goods, services, and facilities that respect the dignity and independence of persons with disabilities. This document is available in an accessible format or with appropriate communication supports upon request.
Page 1 of 5

Section 1 is to be completed by Student.
I consent that the disability information below be released to Disability Services at
Queen’s University. Screen reader users: press the TAB key to move from form element to form element.
First Name: Last Name:
Signature:
Please check this box if you are filling out this form electronically. This represents your signature.
Date (dd/MM/yyyy):
Confidentiality : Information about your disability/health condition is strictly confidential and is not shared with anyone outside of the QSAS without your expressed consent. To read our complete Statement of Confidentiality, please visit our website.
Please note: While students are not legally required to provide a formal medical diagnosis, having this information along with information about you and your disability/health condition enables QSAS to provide you with the best possible service.
Section 2 is to be completed by a Regulated Health Professional.
Screen reader users: press the TAB key to move from form element to form element.
Completed by Regulated Health Professional
(If applicable, please indicate DSM-V diagnoses if known).

Completed by Regulated Health Professional

In your opinion, is this condition:
Permanent – the following three criteria must be met for determination of a permanent disability:
Functional impairments due to the disability
Functional impairments directly impacting participation in post-secondary studies
Functional impairments are expected to be life-long
Temporary – please indicate one of the two following options:
Anticipated duration - from (date dd/MM/yyyy) to (date dd/MM/yyyy)
Unknown - please estimate a reasonable duration:
This condition is not li kely to impair the student’s post-secondary academic performance

What is the nature of this condition (please check all that apply):
Stable
Chronic
Fluctuating
Degenerative
Episodic
Other
Due to the changing nature of the condition the disability status should be reassessed every (frequency):

Completed by Regulated Health Professional
Please list the impairments that affect academic performance (class attendance, reading, writing, note taking, test taking, presenting, participation in labs or tutorials, etc.):
Cognitive
Psycho-Social
Physical
Sensory

In an academic setting, you consider the disability-related impairments to be
(check one):
Mild Moderate Severe

Is the student currently taking medication/s for the condition?
YES NO

Do the impairments persist even with the medication/s?
YES NO
Details:
Do the medications produce any side effects that impact the student’s academic performance?
YES NO
Details:
Note: Please attach any relevant assessment reports (e.g. audiogram) that will help the advisors understand the extent or nature of the impairments.

Section 3 is to be completed by a Regulated Health Professional.
Completed by Regulated Health Professional
How long have you provided service to this student?
Last date of clinical assessment (dd/MM/yyyy)?
Signature:
Please check this box if you are filling out this form electronically. This represents your signature.
Date (dd/MM/yyyy):
Name and Title:
Registration Number:
Address:
Telephone:
Fax: