Disability Assessment Form
Student Information
Student name
First Name
Last Name
Student ID
Birth date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Student's Disability Details
What type of disability does the student have?
Vision Impairment
Deaf/hearing loss
Acquired brain injury
Low vision/blind
Medical/chronic illness
Mental health
Mobility/physical
Other
Detailed explanation of the disability
Nature of disability
Primary
Secondary
Tertiary
Expected duration of disability
Permanent disability with ongoing (chronic or episodic) symptoms that will significantly impact the student over the course of their expected life
Temporary disability with an anticipated duration
Unknown status
Student’s Disability-Related Education Barriers
Academic Tasks
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Listening
1
2
3
4
5
Speaking
6
7
8
9
10
Taking Notes
11
12
13
14
15
Completing Assignments/Reports
16
17
18
19
20
Writing Tests & Exams
21
22
23
24
25
Delivering Presentations
26
27
28
29
30
Meeting Deadlines
31
32
33
34
35
Participating in Group Activities
36
37
38
39
40
Cognitive Skills and Abilities
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Concentration/Attention
41
42
43
44
45
Executive functioning (planning, organizing, problem-solving, sequencing, time management)
46
47
48
49
50
Information Processing
51
52
53
54
55
Long-term memory (recall/retrieve stored information)
56
57
58
59
60
Short-term memory
61
62
63
64
65
Physical Activity Intolerance
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Gross motor: Reaching
66
67
68
69
70
Gross motor: Bending
71
72
73
74
75
Fine motor/manual dexterity
76
77
78
79
80
Climbing (stairs)
81
82
83
84
85
Walking
86
87
88
89
90
Sitting for Sustained Periods
91
92
93
94
95
Standing for Sustained Periods
96
97
98
99
100
Sensory
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Vision: Right Eye
101
102
103
104
105
Vision: Left Eye
106
107
108
109
110
Vision: Bilateral Eye
111
112
113
114
115
Hearing: Right Ear
116
117
118
119
120
Hearing: Left Ear
121
122
123
124
125
Hearing: Bilateral
126
127
128
129
130
Speech
131
132
133
134
135
Socio-emotional
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Fatigue
136
137
138
139
140
Managing a Full Course Load
141
142
143
144
145
Managing Stress
146
147
148
149
150
Mood
151
152
153
154
155
Social Interactions
156
157
158
159
160
Attending Class
161
162
163
164
165
Speech
166
167
168
169
170
You can add any additional functional limitation(s) related to the students academic performance and/or provide any further information
Clinical History
Last date of clinical assessment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How long have you provided service to this student?
Will you continue to provide service to the student?
Yes
No
Unknown
Methods used to diagnose disability and identify functional limitations
Does the student take any medication and/or engage in any treatments that may impact their academic functioning?
Yes
No
Describe the impact(s)
Accommodation Recommendation
Based on the student's disability-related functional limitations, which accommodations or supports do you recommend that will facilitate their participation in post-secondary studies?
Medical Professional Information
Name of certified medical professional
First Name
Last Name
Profession title
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Signature
Submit
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