University Of Toronto Verification Of Student Illness Or Injury

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University of Toronto

Verification of Student Illness or Injury

To be completed only by a Physician, Surgeon, Nurse Practitioner, Registered Psychologist or Dentist

1. TO BE COMPLETED BY THE STUDENT:

STUDENT#__________________________________

I, (please print)____________________________ authorize this practitioner to provide the information on this form relating to

my request for special consideration to the University of Toronto, and to verify the information as required

_________________________________

________________________________

STUDENT SIGNATURE

DATE

2. TO BE COMPLETED BY THE LICENSED PRACTITIONER:

Please indicate below the effect of the illness, injury and/or treatment

on the student’s ability to learn, communicate, concentrate, participate in academic activities as well as his/her decision making

capacity and motivation.

Initial the most

Anticipated

Degree of Incapacitation on Academic Functioning

Start Date

relevant category

End Date

Completely unable to function at any academic level e.g. unable to

Severe

attend classes, or fulfill any academic obligations.

Significantly impaired in ability to fulfill academic obligations e.g.

Serious

unable to complete an assignment, unable to write a test/examination

May be able to fulfill some academic obligations but performance

considerably affected e.g. able to attend some classes, decreased

Moderate

concentration, assignments may be late

Likely to be able to fulfill academic obligations, but performance

affected to a minor degree, with mild impairment and minimal

Mild

symptoms

Unlikely to have an effect on ability to fulfill academic obligations

Negligible

√

Frequency and/or timeline of contact with student relevant to present illness/episode of illness/injury

□

Once Only - Visit Date:

□

Multiple/On-going - Visit Dates:

Additional Comments:

3. VERIFICATION BY THE LICENSED PRACTITIONER:

This form is based on examination and applicable documented history at the time of illness or injury, not after the

fact. I certify that this assessment falls within my legislated scope of practice.

_________________________________

Business stamp, with address and telephone

NAME (Please Print)

____________________________________

Licencing Body and REGISTRATION #

_________________________________

_____________________________

SIGNATURE

DATE

The University of Toronto respects personal privacy. Personal information that is provided on this form is used by the University to verify effects of illness or

injury on your capabilities and necessary related purposes. At all times it will be protected in accordance with the Freedom of Information and Protection of

Privacy Act. If you have questions, please contact your campus administrator.

Alteration or falsification of information on this form may constitute an academic offence under the Code of Behaviour on Academic Matters and may be

prosecuted as such.

Completion of this form does not guarantee that special consideration will be granted. Incomplete forms will not be processed.

In some appeal situations, the University may require additional information from you or your practitioner to decide whether or not to grant or

confirm special consideration.

PLEASE RETAIN A COPY FOR YOUR FILES