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
 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:________________
________________________
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
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
Degree:
____________________
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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Initial Questionnaire for Students with Temporary Disabilities or Injuries
If you require assistance completing this form or need it in an alternative format, please
ask at the front desk.
Please answer the following questions as completely as possible. The information you
provide will help us develop an accommodation plan that meets your individual needs.
1. What is your temporary disability or injury?
______________________________________________________________________
______________________________________________________________________
2. Please list your current medications and any side effects.
______________________________________________________________________
______________________________________________________________________
3. Please list any health-related program, treatment or therapy that you attend or do.
______________________________________________________________________
______________________________________________________________________
4. What challenges does your disability or injury pose for you at university?
______________________________________________________________________
______________________________________________________________________
5. What strategies are you using to cope with these challenges?
______________________________________________________________________
______________________________________________________________________
6. Have you missed class as a result of your disability or injury?  No  Yes
7. Have you ever had a head injury?
 No  Yes
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8. Are you currently registered at the U of T?  No  Yes
9. When did you first register at the U of T? ______________________
10. What are your reasons for attending the U of T (academic/career goals)?
______________________________________________________________________
______________________________________________________________________
12. Have you ever been on academic probation or suspension?  No  Yes
If yes, please provide details.
______________________________________________________________________
______________________________________________________________________
13. Have you applied for OSAP?  No  Yes  are you eligible?  No  Yes
14. How many hours a week do you spend:
 Studying
# ____hours
 Paying job
# ____hours
15. 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
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 Temporary Disabilities or Injuries
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 or surgeon,
with the following information:





Date of Injury
Diagnosis/detailed description of injury
Treatment plan (including but not limited to surgery, casting, splints,
physiotherapy)
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.
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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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 disability-related 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 TEMPORARY INJURY 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

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 Sports Medicine Specialist
o Surgeon
 Other: ___________________________
Health Practitioner Signature:
License / Registration No.
Date
Telephone No.
Fax. No
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