# Medical Documentation Form This form is not meant for you if your accommodation needs: | | | |---|---| | Type | PDF | | Size | 305 KB | [Open original PDF →](https://www.northerncollege.ca/uploads/2025/07/Medical-Information-Request-Form.pdf) Referenced from: [Registration with Accessibility Services](/pages/student-life/registration/) ## Document text ⃝ ⃝ ## Medical Documentation Form ## IMPORTANT NOTE REGARDING THIS FORM This form is not meant for you if your accommodation needs: - Are the result of a non-disability-related extenuating circumstance (i.e. death in family, etc.) * - Are the result of a learning disability* * Please consult with your accessibility office rather than completing this form ## PART A: TO BE COMPLETED BY THE STUDENT This form is designed to provide Northern College's Accessibility Services with confirmation that you have a disability and with information on how your disability will impact you while studying at Northern College. The mandate of Northern College's Accessibility Services, informed by the Ontario Human Rights Code, is to provide individualized academic accommodations to equalize learning opportunities. Accessibility Services will use the information provided by your health care provider to work with you to determine what accommodations you will need while you are studying at Northern College. The regulated health care professional who completes this form will be asked to use their assessment and detailed knowledge of you to describe the functional impact of your disability. Please bring this form to a health care professional who knows you well. Disclosing a diagnosis is a choice and is not required to receive accommodations from Northern College's Accessibility Services. Please indicate below if you give consent for your regulated health care provider to disclose your diagnosis. Any information provided on this form is kept strictly confidential and will not be shared with anyone outside of Accessibility Services without your explicit written consent. ⃝ ⃝ Student Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: (D/M/Y) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ## STUDENT INFORMATION Name: Date of Birth (D/M/Y): Student Number: Email: Preferred Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Will you be required to complete fieldwork/placements? - [ ] Yes - [ ] No Type of fieldwork: Date fieldwork begins (D/M/Y): ## CONSENT TO RELEASE INFORMATION I (your name) authorize my health care professional to provide information outlined in this form to the Northern College Accessibility Services Department) ## CONSENT TO DISCLOSURE OF DIAGNOSIS TO NORTHERN COLLEGE'S ACCESSIBILITY SERVICES - [ ] I consent to my diagnosis being identified on this form and provided to Northern College's Accessibility Services - [ ] I do not consent to my diagnosis being identified on this form ## PART B: TO BE COMPLETED BY THE HEALTH CARE PROFESSIONAL You are being asked to complete the following Documentation Form by a student who wishes to register with Accessibility Services at Northern College. We seek the following information: 1. Confirmation that the student has a disability 2. Confirmation of functional limitations the student experiences directly related to their disability or health condition We rely on your assessment and detailed knowledge of this student and their disability to provide us with a description of the current functional limitations that impact the student in the academic context. Please use the form that follows to identify the functional limitations that impact the student in the academic context. In some cases, students will complete the Functional Limitations section themselves. If this is the case, we ask that you initial each functional limitation indicated by the student with which you agree. By initialing in agreement, you are indicating that you have assessed this functional limitation and agree that the limitation is present OR based on your knowledge of the student's condition, this limitation is related to the student's diagnosed disability(ies). The information you provide, along with the information provided by the student, will be used by Northern College's Accessibility Services to design an individualized accommodation plan. This plan helps to ensure the student has an equitable opportunity to fulfill the essential academic requirements and standards at Northern College. Disclosing a diagnosis is not required to access accommodations from Northern College. You are asked to only provide a diagnosis with the student's consent on the CONFIRMATION OF DISABLITY page of this form. Any information provided on this form will be kept strictly confidential and will not be shared with anyone outside of Northern College's Accessibility Services without the student's written consent. ## CERTIFICATION OF REGULATED HEALTH CARE PROFESSIONAL Practitioners Name (print): Phone: Fax: License/Registration Number: Regulated Health Care Professional: - [ ]  Physician - Family - [ ]  Physician - Specialty - [ ]  Psychologist/Psychological Associate - [ ]  Other Regulated Health Care Profession Practitioner's Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ *Note: If you do not have an official stamp, please sign, date, and attach a sheet of your office letterhead. Practice Stamp ## Confirmation Of Disability (To be completed by the Health Care Professional) Please Note : If this student's functional limitations are a result of a non-disability related extenuating circumstance (e.g., death in family) please have the student consult with their respective postsecondary accessibility office rather than completing this form. The following criterion MUST BE MET for the determination of a disability: The student experiences functional impairments due to a disability or diagnosed health condition that impacts the student's academic functioning while pursuing postsecondary studies. ## DURATION OF DISABILITY The designation of permanent, persistent, or prolonged disability has legal implications and is used in determining a student's eligibility for government programs. ⃝ ⃝ ## Disability Duration: - [ ] o Permanent disability - ongoing, will impact the student over the course of their academic career, such as any impairment, including a physical, mental, intellectual, cognitive, learning, communication or sensory impairment-or a functional limitation-that: restricts a student's ability to perform the daily activities necessary to pursue studies at a postsecondary school level, and is expected to remain with the student for their expected life. - [ ] o Persistent or prolonged disability - as per above but is expected to last for a period of at least 12 months but is not expected to remain with the student for their expected life. - [ ] o Temporary disability Anticipated duration: (M/Y) to (M/Y) - [ ] o Diagnosis unconfirmed (Note: interim accommodations offered under these circumstances may require periodic documentation from professionals) Assessment likely to be completed by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(M/Y) Next clinical assessment appointment: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(M/Y) Notes/Comments: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Has the student consented to providing their diagnosis(es) in Part A? - [ ] Yes - [ ] No If Yes , please provide the diagnostic statement(s): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ⃝ ## EXPECTED CHANGES IN LEVEL OF FUNCTIONING ⃝ ⃝ - [ ] Condition is expected to remain stable - [ ] Condition is expected to fluctuate significantly - [ ] Condition is expected to decline - [ ] Changes in level of functioning are difficult to predict Does this student have a disability that is episodic in nature (i.e., periods of good health interrupted by periods of illness or disability?) - [ ] o Yes - [ ] o No If the student's functioning is restricted at certain times of the day, please specify when: - [ ] o Morning - [ ] o Afternoon - [ ] o Evening - [ ] o Not Applicable ⃝ ## Functional Limitations (To be completed by Health Care Professional) ## Please check all functional limitations the student experiences specifically due to their disability Note: If the student completes this section of the form, we ask health care providers (HCP) to initial those functional limitations with which they agree, based on their clinical assessment and judgement. ## Communication: \_\_\_\_ Not Applicable | Condition significantly restricts ability to: | Yes | HCP Initial | | --- Source: [https://www.northerncollege.ca/uploads/2025/07/Medical-Information-Request-Form.pdf](https://www.northerncollege.ca/uploads/2025/07/Medical-Information-Request-Form.pdf)