UNIVERSITY OF TORONTO
ACCESSIBILITY SERVICES
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 Sensory, Physical, Chronic & Mental Health
Related Disabilities
To receive support from Accessibility Services a student must “communicate his or her needs in sufficient
detail and co-operate in consultations to enable the person responsible for accommodation to respond to
the request.” (Ontario Human Rights Code Guidelines, 1994, p.17). The OHRC Guidelines (1994) also
note that the university, as the body responsible for accommodating, must have sufficient information “to
properly assess the impact of the disability on the specific academic task and know how to make the
requested accommodation.”
In order to be accommodated, students who register with Accessibility Services who have sensory,
physical, chronic and /or mental health- related disabilities must provide sufficient documentation to verify
the disability and its functional impact on the student’s academic performance.
Documentation must be provided by a practitioner who is certified in the area specific to the disability
(e.g., a psychiatric diagnosis may come from a psychiatrist, registered psychologist or family
physician/general practitioner).
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RELEASE OF INFORMATION
TO BE COMPLETED BY STUDENT
I,__________________________________________, hereby authorize the above named professional
to provide the following information to Accessibility Services at the University of Toronto and if required to
supply additional information relating to the provision of my academic accommodations and disabilityrelated services. I also authorize Accessibility Services to contact the physician to discuss the provision
of accommodations.
Student’s Signature:_________________________________________
University of Toronto Student Number: __________________________
Date:___________________________
Thank you for taking the time to complete this form
The information will facilitate the supports requested by your patient while at the
University of Toronto
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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 SENSORY, PHYSICAL, CHRONIC & MENTAL HEALTH RELATED ISSUES
This student is requesting disability-related supports and accommodations while studying at the University of
Toronto. In addition, this medical documentation may be used to access financial funds through the Bursary for
Students with Disabilities and the Canadian Grant for Students with Permanent Disabilities. The student is required
to provide the University with documentation that:
• is provided by a licensed health-care professional, qualified in the appropriate specialty
• provides detailed documentation, evidence of assessment, and sufficient explanation 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/re-assessment 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 QUALIFIED IN THE APPROPRIATE SPECIALTY
– PLEASE PRINT CLEARLY
*Mandatory Questions
*Student’s Name: ______________________________________________________________
*University of Toronto Student Number:
*Date of Birth: _____/_____/_____ (Year, Month, Day)
*How long have you been treating this patient? _______________________________________
**Last date of Clinical Assessment: _________________________________________________
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STATEMENT OF DISABILITY
Please indicate the appropriate statement for this student in the current academic setting:
Check box for either permanent or temporary disability

PERMANENT DISABILITY
Identification/designation of a permanent disability is usually determined after considerable assessment, treatment and/or
observation of the patient. A permanent disability involves on-going (chronic or episodic) symptoms (that will significantly
impact the student over the course of his/her academic career). To designate a permanent disability, an evaluation has been
conducted that involved the use of assessment tools/techniques that examined the functional impact of the disability as well as
the permanence of the observed/assessed limitations. Multiple visits and observations of the patient in addition to review of
pertinent medical history documentation are necessary to determine permanence of a disability. Typical examples of a
permanent disability include (but are not limited to): neurodevelopmental disorders (e.g., ADHD, learning disability, autism
spectrum disorder); chronic health conditions (e.g., diabetes, epilepsy); sensory disorders (e.g., deafness, low vision,); mobility
impairments (e.g., cerebral palsy, paraplegia, arthritis); and, chronic mental health conditions (e.g., dysthymia, bipolar
disorder, persistent Generalized Anxiety Disorder).
Students with documentation that identifies a permanent disability may be able to access funds/fee adjustments from
government assistance programs including but not limited to OSAP as well as other accommodations. In evaluating
permanence of a disability, for OSAP purposes, the Canadian Student Loan program defines a permanent disability as
“a functional limitation caused by a physical or mental impairment that restricts the ability” of a student “to perform the
daily activities necessary to participate in studies at a post-secondary level or the labour force and is expected to remain
with a student for his/her “expected life”. (DD. Gov. of Can. Section 4.5, 2003)

TEMPORARY DISABILITY
A disability is designated as temporary in the following situations:
The disability will only last for a determined period of time. Indicate the time period outlining duration from
___/___/___ to ___/___/___ (Year, Month, and Day) *If unknown, please indicate reasonable duration for which s/he
should be accommodated/supported at this time (please specify number of weeks/months):
THIS SECTION MUST BE COMPLETED if indicating the disability is Temporary. Accommodations will not be extended
beyond dates listed above without updated documentation prior to the expiry date of the temporary disability listed above.
Typical examples of a temporary disability include (but are not limited to): orthopedic injuries (e.g., broken leg, injured back,
concussions/mild TBIs, initial episode of a mental health condition, surgical recovery, serious infections).
A temporary disability certificate has a maximum duration of 6 months. Should the period of disability still be
active beyond this point, a new certificate is required.
Or
The disability is currently under review/still being assessed and sufficient assessment and observation of the
patient has not been completed yet to allow determination of the permanence of temporary nature of the disability.
When the diagnosis is still being considered (i.e. it is a “working diagnosis”), designate the disability as
temporary. When the assessment is complete, provide updated documentation as to whether the disability
remains temporary or can now be listed as permanent.
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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 Mental Health Disability: (a DSM IV; DSM V; ICD-10 diagnosis)
_______________________________________________________________________________________
Secondary Mental Health Disability: (a DSM IV; DSM V; ICD-10 diagnosis)
_______________________________________________________________________________________
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) THAT IMPACT ACADEMIC PERFORMANCE:
_________________________________________________________________________________________
Current treatment: (counseling, psychotherapy, acupuncture, massage therapy, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
IMPACTS ON ACADEMIC FUNCTIONING (please specify where possible)

Energy level (please specify impact e.g. fluctuating): ___________________________________________

Impact on sleeping cycles: _______________________________________________________________

Ability to manage full academic work load:
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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:
__________________________________________________________________________________________
ACCOMMODATIONS
(Please list recommendations below. The disability counsellor will discuss the recommendations with the
student. Accommodations will be put in place that are in line with sufficient/proper documentation and
following discussion between the student and his/her disability counsellor.

Test/ Exam Accommodations (may include considerations related to time, space, equipment and/or
environment modifications)
(Specify):____________________________________________________________________________

Adaptive Technology Assessment is recommended (the student presents with cognitive/physical/motor
and/or health difficulties that warrant further assessment for possible adaptive equipment to assist with
academic studies)

Other Recommendations: Circle any that apply: light box, counselling, massage therapy; yoga/meditation;
ergonomic furniture; physiotherapy
Other (please specify): _______________________________________________________________________
Treating professional’s signature required on next page
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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:
Psychologist
Physician
o Family
o Psychiatrist
o Ear, Nose and Throat Specialist
o Ophthalmologist
Audiologist
o Occupational Therapist
o Speech Pathologist
Other: ___________________________
Health Practitioner Signature:
License / Registration No.
Date
Telephone No.
Fax. No
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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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