Verification Of Temporary Disability Form

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Building 200, 900 Fifth Street, Nanaimo, BC V9R 5S5
phone: 250-740-6446
fax: 250-740-6615
Verification of Temporary
Disability Services
Disability Form
Name of Patient: ______________________________________________________________
Date: ________________________________
Vancouver Island University requires that Disability Services verify a student’s disability, injury, or
illness in order to provide support services. The above named individual has requested services
due to a temporary disability. Based on your knowledge of the student’s condition, please
indicate on this form the nature of the disability, anticipated duration, and the services that would
be most appropriate.
Anticipated Duration of Services: _________________________________________________
DISABILITY:
Mobility
Visual
Hearing
Other (please specify) ____________________________________________
_______________________________________________________
_________________________________________________________________________
SERVICES:
Accommodated Exams
Note-taker
Other (please specify) ____________________________________________
__________________________________________________________________
__________________________________________________________________
PHYSICIAN NAME: _________________________________________________________________________
ADDRESS :
_________________________________________________________________
_________________________________________________________________
PHYSICIAN SIGNATURE: ____________________________________________________________________
S:FORMSDOCVerification of Temporary Disability rev'd 08.doc

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