Disability Assessment Form
Student Information
Student name
First Name
Last Name
Student ID
Birth date
-
Month
-
Day
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
Speaking
Taking Notes
Completing Assignments/Reports
Writing Tests & Exams
Delivering Presentations
Meeting Deadlines
Participating in Group Activities
Cognitive Skills and Abilities
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Concentration/Attention
Executive functioning (planning, organizing, problem-solving, sequencing, time management)
Information Processing
Long-term memory (recall/retrieve stored information)
Short-term memory
Physical Activity Intolerance
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Gross motor: Reaching
Gross motor: Bending
Fine motor/manual dexterity
Climbing (stairs)
Walking
Sitting for Sustained Periods
Standing for Sustained Periods
Sensory
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Vision: Right Eye
Vision: Left Eye
Vision: Bilateral Eye
Hearing: Right Ear
Hearing: Left Ear
Hearing: Bilateral
Speech
Socio-emotional
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Uncertain
Fatigue
Managing a Full Course Load
Managing Stress
Mood
Social Interactions
Attending Class
Speech
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
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
Submit
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