ATHABASCA UNIVERSITY
Access to Students with Disabilities
VERIFICATION OF ACCOMMODATION & SUPPORT SERVICE REQUIREMENTS
To apply for accommodations and services offered through Access to Students with Disabilities,
please print this form. Once you have completed Part I: Self-Assessment and Part II: Release of
Information of the application, please have Part III: Professional Verification filled in and signed by
an appropriate medical or disability services provider/professional and/or provide alternate
supporting documentation of disabling condition as per Appendix A. Once the form has been
completed and all relevant documentation attached, fax it to (780) 421-2546 or mail the package
to the Access to Students with Disabilities Office, Athabasca University, Edmonton Learning Centre,
Peace Hills Trust Tower, 1200, 10011 – 109 Street, Edmonton, Alberta, T5J 3S8. If you have
questions or require assistance to complete the form, contact the ASD office at (780) 497-3424 or
1-800-788-9041 ext. 3424 or by e-mail asd@athabascau.ca.
Part I: Student Information & Self-Assessment
Student Information
Name:
Athabasca University ID#
Are you a Graduate or Undergraduate Student?
Mailing Address:
Telephone Number (including area code):
E-mail Address:
For ASD Office Use Only
1200, 10011 109 Street, Edmonton, AB T5J 3S8 Canada
P: 780.497.3424 | Toll-free (CAN/U.S.) 1.800.788.9041
athabascau.ca
Self-Assessment
ASD and Athabasca University respects the relevance of the self knowledge and experience that an individual
possesses with regard to their abilities and differences. The information that you present through this selfassessment will provide an excellent foundation to enter into discussion with ASD staff and work
collaboratively to identify reasonable accommodations that will meet your individualized needs and provide
the best possible opportunity for access and success in courses at Athabasca University.
Information Related to Disablement in the Educational Environment
1. Please provide a brief statement describing the nature of your permanent or temporary disability
and/or medical condition and how it impacts upon you in the study environment. Including
relevant information of any secondary or multiple diagnoses or the effects of any treatments
(prescription drugs or therapy) you are receiving may assist our office to review your request for
accommodation.
2. Please identify how your medical and/or disabling condition may affect any of the following areas
and the impact this may have upon your ability to pursue studies with Athabasca University (please
provide specific examples)
Absenteeism
Concentration, attention and focus
Distractibility
Stamina/energy/endurance
Ability to multitask
Organization and time management
Stress or anxiety level
Physical strength/dexterity
Process auditory information
Social interaction
Resiliency to change
Communication skills
Vision
Hearing
Pain
Reading
Writing
Previous Educational Accommodations
3. Have you previously received educational accommodations or supports?
___ Yes
___ No
a. If yes, please list the accommodations or supports you received. Be sure to include
course/academic accommodations support service (readers, scribes, aides, etc.) or
learning assistance (strategists, tutors, etc.), alternate format requirements, and exam
accommodations.
Available Assistive Technology
4. Please list any computer hardware or software that you have available to assist you in your studies
(i.e. computer, scanner, printer, voice recognition software, screen magnification software, screenreading software, etc.):
5. Would you like to speak with someone regarding assistive technologies that may be able to assist
you in your studies?
Accommodations Requested at Athabasca University
6. Please provide a preliminary list of the accommodations that you feel that you will require at
Athabasca University. (Accommodations may include additional time to write examinations,
private room to write examinations, additional time to complete courses, etc.)
7. Do you wish to apply to be qualified as a full time student on reduced 40 percent course load? (Only
students with PERMANENT disabilities)
8. Would you like to speak with someone regarding acquiring your course materials in an alternate
format to accommodate your disabling condition (for example materials in large print, electronic
text, print/hard copy, audio format, etc.)?
Applicant Declaration:
In making this application to the Access with Students with Disabilities Office to request
services and/or academic accommodation as a student with a disability I acknowledge that the
above information presents an accurate reflection of my needs based upon my knowledge and
experience of my condition.
I understand that I am responsible for maintaining communication with the Access to
Students with Disabilities Office regarding my needs and for participating on an ongoing basis in
the accommodation process. I understand that additional supporting documentation may be
required to support my request for services and/or academic accommodation.
I understand that my request for services and/or academic accommodation will be
reviewed with Access to Students with Disabilities Office in order to identify what is reasonable
in consideration of my functional abilities and differences, treatment, symptoms, academic
requirements, eligibility for funding, environment, geographic location and other available
resources. Reasonable accommodations and support services will be assessed based upon
individual abilities and differences and in consideration of academic or program requirements.
As a result not all requested services and/or academic accommodations may be approved.
I understand that Access to Students with Disabilities may be required to disclose
information regarding my assessed academic accommodations to third parties in order that I
may access these accommodations.
____________________________________________
_________________________
Signature
Date
Part II: Release of Information Authorization
Student Name:
Athabasca University ID#
RELEASE OF INFORMATION:
The following section must be completed by the applicant:
Please provide the name and contact information for the medical or disability services
provider/professional who you have requested to verify your disabling condition and accommodation
requirements.
Name of Individual:
Position/Title:
Professional Relationship to applicant (i.e. family physician, medical specialist, psychiatrist, educational
service coordinator, etc.):
Agency/Institution:
Address:
Phone:
Fax:
E-mail:
Release of Information Waiver:
For the purpose of verifying that the self-identified differences and requested accommodations
are considered valid and are directly related to a need that arises from a disabling or medical
condition, or subsequent treatment thereof, and to enable Athabasca University to properly
assess what accommodations are appropriate, I authorize the agency and/or individual
identified above to release relevant medical or educational assessment documentation and
information to Access to Students with Disabilities, Athabasca University, as well as to any other
Athabasca University official or legal advisor designated by ASD, where such release is
necessary to permit Athabasca University to determine whether proposed accommodations are
reasonable and do not constitute an undue hardship. Typically, ASD will not provide this
information to persons other than ASD staff.
I further authorize any additional required communications between the agency and/or
individual identified above and the staff of Access to Students with Disabilities, Athabasca
University, to obtain more information or clarification on the disabling or medical condition (or
subsequent treatment) with specific regard to the determination of an appropriate
accommodation in the post-secondary environment.
I specifically authorize the agency and/or individual named above to release the following
documents which should then be attached to this completed application:
___
___
___
___
___
___
___
___
___
psycho-educational assessment
neuro-psychological assessment
psychiatric reports/assessment
audiology report/assessment
ophthalmology report/assessment
medical report
educational reports
information regarding education accommodations
other:
___ ________________________________________
___ ________________________________________
___ ________________________________________
____________________________________________
_________________________
Signature
Date
Note: This waiver is in effect until the student notifies the Access to Students with Disabilities Office,
Athabasca University, in writing, of the withdrawal of this authorization.
Please Note: The application and use of this authorization to release information is restricted to
Access to Students with Disabilities Department and such other Athabasca University officials or legal
advisors as are specifically designated by ASD. Students should complete the required request forms
for any documentation requests by other Departments or Services within Athabasca University.
All information or documentation received by the ASD Office will be maintained in strictest
confidence and within the guidelines of the Alberta Freedom of Information and Protection of
Privacy Act and shared only with such other Athabasca University officials and legal advisors as
designated by ASD and who are required to receive the information to make final assessments
as to whether the accommodations sought are reasonable and do not constitute an undue
hardship. Please see the FOIP statement at the bottom of this Form for further information.
PART III: PROFESSIONAL VERIFICATION
Student Name:
Athabasca University ID#
The following section is to be completed by the professional that has been designated by the applicant
in Part 2 of this application. Please review Appendix A for further information regarding who may
complete this form and/or alternate documentation that may be provided to support the request for
accommodation.
Name:
Position/Title:
Credentials:
Response to the following questions will enable ASD to work in collaboration with the applicant to
determine the best possible accommodation solutions. The information that is collected will also assist
ASD staff to identify funding and other resource options available to students with disabilities for which
this applicant may be eligible. Please attach any assessments or documents that have been
authorized for release by the applicant.
ASD Eligibility criteria: Enrolled or prospective students with functional differences resulting from
disabilities or medical conditions that are sensory, learning, physical/mobility, neurological,
psychological, permanent or chronic disabilities or medical conditions, or injuries that are temporary in
nature and necessitate accommodation in the education environment are eligible for ASD services.
1. In your professional opinion does this applicant meet the eligibility criteria to receive service or
accommodation?
___ Yes
___ No
2. Do you consider this individual’s disability/condition to be:
___ Permanent
___ Chronic (condition has or is expected to persist for more than 3 years)
___ Temporary
If the condition is temporary, by what date would you expect sufficient recovery to eliminate
the need for accommodation? ____________________________
3. At the present time, would you recommend this student should proceed with a course load:
___ part time studies (20 – 40% course load)
___ student should be considered full-time with a reduced course load
(40% course load)
___ full time studies (60 – 100% course load)
Professional Verification.
Please advise as to whether, in your opinion, the Applicant has any disabilities either as selfidentified or otherwise. Please also comment on what, if any, educational accommodations you
consider to be necessary and directly arising from the disabling or medical condition you have
verified or any subsequent treatment thereof. Also indicate whether you believe the Applicant
would benefit from the use of any specific services such as alternate format (e.g. print hard copy,
eText, audio) or assistive technologies (e.g. voice recognition, text to voice, computer, etc.) to
assist the Applicant in accessing or successfully completing courses.
The information contained in this professional statement are within my professional expertise
and knowledge that I have of this Applicant
____________________________________________
_________________________
Signature of Professional
Date
Please return completed form to:
Attention: Professional Services Coordinator
Access to Students with Disabilities
Athabasca University Edmonton
Peace Hills Trust Tower
1200, 10011 – 109 Street
Edmonton, AB T5J 3S8
The personal information collected on this form will be used to verify the presence of a disabling or medical condition to determine eligibility for ASD
services and accommodations. This information is collected under the authority of section 33 ( c ) of the Alberta Freedom of Information and
Protection of Privacy Act. If you have any questions about the collection and use of this information, contact the Professional Services Coordinator,
Access to Students with Disabilities, Athabasca University Edmonton, Peace Hills Trust Tower, 1200, 10011 – 109 Street , Edmonton, Alberta, T5J 3S8,
(780) 497-3424 or 1-800-788-9041 ext. 3424.
Appendix A: Summary of Disability Documentation Required
In order to register for services with ASD, in addition to completing Part I and Part II of this
form you must also include documentation that confirms presence of your disabling
condition and how your disabling conditions affects your ability to pursue post-secondary
studies. Please review below to identify the type of documentation that you may submit in
order to confirm presence of your disabling condition.
Type of Disability
Deaf, Hearing Impaired
Documentation Required
Audiologist report, or
Letter from a physician with an explanation of the degree of hearing loss, or
Completion of Professional Verification (page 8) by physician with details
regarding how your disabling condition impacts upon ability to pursue postsecondary studies
Blind, Visually Impaired
Specialist report, or
Letter from a physician with a description of the functional limitations, or
Completion of Professional Verification (page 8) by physician/specialist with
details regarding how your disabling condition impacts upon ability to pursue
post-secondary studies
Learning Disability
Speech
Psycho-educational report from a Psychologist completed as an adult, or
Neuro-psychological report completed as an adult with details regarding how
your disabling condition impacts upon ability to pursue post-secondary studies
Speech language pathologist report, or
Completion of Professional Verification (page 8) by speech
pathologist/specialist with details regarding how your disabling condition
impacts upon ability to pursue post-secondary studies
Specialist report, or
Mobility/Agility Impairment
Letter from a physician with an explanation of the nature of the mobility/agility
impairment (functional limitation), or
Completion of Professional Verification (page 8) by physician/specialist with
description of the functional limitations how they impact upon ability to pursue
post-secondary studies
Psychologist report, or
ADD / ADHD
Neuro-psychological report, or
Letter from a psychiatrist, or
Letter from a physician with details about the diagnosis, or
Completion of Professional Verification (page 8) by a psychiatrist/psychologist
or physician with details regarding how your disabling condition impacts upon
ability to pursue post-secondary studies
Psychologist report with a DSM diagnosis, or
Psychiatric or Psychological
Letter from a psychiatrist with a DSM diagnosis, or
Letter from a physician with details about the diagnosis including the DSM, or
Completion of Professional Verification (page 8) by a psychiatrist/psychologist
or physician with details regarding how your disabling condition impacts upon
ability to pursue post-secondary studies
Autism, Asperger, Rett
Psychologist report, or
Letter from a physician with details about the diagnosis, or
Completion of Professional Verification (page 8) by a psychologist or physician
with details regarding how your disabling condition impacts upon ability to
pursue post-secondary studies
Brain Injury/Cognitive
Impairment
Neuro-Psychological report, or
Brain injury/cognitive impairment report/assessment, or
Completion of Professional Verification (page 8) by a physician/specialist with
details regarding how your disabling condition impacts upon ability to pursue
post-secondary studies
Other Permanent or Temporary
Disabling Condition
Completion of Professional Verification (page 8) by a physician/specialist with
details regarding how your disabling condition impacts upon ability to pursue
post-secondary studies