Documentation Form Of Physical Disability - Student Development printable pdf download

Documentation Form Of Physical Disability - Student Development

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Documentation of Sensory, Physical and Medical Disabilities

Services for Students with Disabilities

Student Development Centre

1151 Richmond Street, London, Ontario, Canada, N6A 3K7

t: 519 661 2147

f: 519 850 2584

w: sdc.uwo.ca/ssd

e: ssd@uwo.ca

Purpose of this form

Services for Students with Disabilities (SSD) requires documentation from a licensed health care

professional, who is qualified to communicate a diagnosis and has in-depth knowledge of a student’s

condition, in order to arrange academic accommodation and/or related services. Information on this form

also may be used to assess a student’s eligibility for financial support. Documentation should be as

complete as possible in order to facilitate SSD’s assessment of a student’s request for services.

_________________________________________________________________________________________

To be completed by student

Student Name:

Date of Birth:

______/______/______

(Year/Month/Day)

Student Number:

_______________________________

I authorize the professional named below to disclose to Services for Students with Disabilities (SSD)

information on this form and additional or clarifying information that is necessary for provision of disability

services at Western University. I also authorize SSD to communicate with this professional in order to

obtain information that is relevant to provision of SSD’s services.

Date : _____________ __________________ Student Signature : _________________________________

Student’s informed authorization for disclosure of information is obtained in accordance with the following sections of the

Freedom of Information and Protection of Privacy Act. Sections 41.(1)(a), 41.(1)(b), and 41.(1)(c) allowing for the use of

personal information and sections 42.(1)(b),

s.42(1)(c), and s.42(1)(d) allowing for the disclosure of personal information.

____________________________________________________________________________

To be completed by licensed health care professional

Name (please print):

Registration Number:

_______________________________________

___________________________________

Address of medical professional:

_______________________________________

Telephone #: ________________________

_______________________________________

Fax #: _____________________________

Profession:

2 Family Physician

2 Pediatrician

2 Other_________________

Signature:

Date:

________________________________________

___________________________________

Documentation Form Of Physical Disability - Student Development

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