Health Certificate - Conestoga CollegeHealth Certificate Attention Health Care Practitioner: This...
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Health Certificate Attention Health Care Practitioner: This Health Certificate will be used as one of the criteria to determine the student's eligibility to receive academic accommodations, support services and financial supports at Conestoga College. Section A: To be completed by the student: Student Name: Last Name First Name Student Number: Date of Birth: Address: Phone Number: Student Consent for Release of Information: I , hereby authorize the Health Care Practitioner to provide the following information to Accessible Learning - Student Success Services, Conestoga College and, if required, to supply additional information relating to my disability. I also authorize Accessible Learning - Student Success Services, Conestoga College, to contact the Health Care Practitioner to discuss the provision of accommodations. Student Signature Date Section B: To be completed by a regulated Health Practitioner – please print clearly How long has the student been your patient? One visit Less than one year More than one year Duration of the student's disability (check one): This student's disability is: permanent temporary being monitored to determine a diagnosis The symptoms are: continuous recurring Accommodations should be put in place: permanently temporarily FROM TO Medication If the student has been prescribed medication, when is the medication most likely to impact academic functioning? Morning Afternoon Evening N/A Comments: Page 1 of 3
Transcript of Health Certificate - Conestoga CollegeHealth Certificate Attention Health Care Practitioner: This...
Health Certificate
Attention Health Care Practitioner: This Health Certificate will be used as one of the criteria to determine the student's eligibility to receive academic accommodations, support services and financial supports at
Conestoga College.
Section A:
To be completed by the student:
Student Name:Last Name First Name
Student Number:
Date of Birth:
Address:
Phone Number:
Student Consent for Release of Information:
I , hereby authorize the Health Care Practitioner to provide the following
information to Accessible Learning - Student Success Services, Conestoga College and, if required, tosupply additional information relating to my disability. I also authorize Accessible Learning - Student Success Services, Conestoga College, to contact the Health Care Practitioner to discuss the provision ofaccommodations.
Student Signature Date
Section B:
To be completed by a regulated Health Practitioner – please print clearly
How long has the student been your patient? One visit Less than one year More than one year
Duration of the student's disability (check one):
This student's disability is: permanent temporary being monitored to determine a diagnosis
The symptoms are: continuous recurring
Accommodations should be put in place: permanently
temporarily FROM TO
MedicationIf the student has been prescribed medication, when is the medication most likely to impact academicfunctioning? Morning Afternoon Evening N/A
Comments:
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Functional Impact: Current symptoms of condition and/or medication(s) which may affect academic life
Skills / Abilities No Mild Moderate Severe Not Impact Impact Impact Impact Sure
Attention/concentration
Long-term memory
Short-term memory
Executive functioning
Information processing
Ability to manage distraction-filter out distracting visual and auditory stimuli
Judgment-anticipating the impact of one's behaviour on self and others
PHYSICAL
Attendance/absence from Class
Stamina (academic)-ability to complete a full course load
Stamina (field work)-ability to complete a 35 hr work week
Mobility
Gross motor
Fine motor
Ability to sit for sustained periods
Ability to stand for sustained periods
SENSORY
Vision (best corrected) describe below:
Hearing (best corrected) describe below:
Speech: describe below:
COGNITION
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SOCIAL/EMOTIONAL No
Impact Mild Impact
Moderate Impact
Severe Impact
Not Sure
Appropriate in-class and group work interactions
Ability to perform class presentations
Reading social cues
Ability to manage stress during class
Ability to manage stress during tests
Effectively control emotions
Other:
Additional comments or elaboration:
Section C:
Certification of Health Practitioner
Practitioner's First and Last Name
Health Practitioner Signature
Date
Address or Business Stamp:
License or Registration #
Type of Health Practitioner: Physician Psychologist Psychiatrist Other:
Student Consent for Disclosure of Diagnosis (to be completed by student AND Health Care Professional):
A diagnosis is required to access some government financial aid opportunities for students with disabilities. If you wish to be eligible for these opportunities, you must provide consent for your health care professional to disclose your diagnosis here. Please note that disclosure of a diagnosis is NOT required to provide most academic accommodations.
I , hereby authorize the health practitioner to disclose my diagnosis to Student Success Services.
Student Signature:
To be completed by Health Care Practitioner
Diagnosis:
PLEASE SUBMIT COMPLETED FORM TO: Accessible Learning - Student Success Services, Conestoga College 299 Doon ValleyDrive, Room 2A103 Kitchener, ON, N2G 4M4 519-748-5220 ext. 3232, FAX 519-748-3507
[email protected] www.studentsuccess.conestoga.on.caPage 3 of 3
