Disability Assessment Form

Helps clinicians document how a medical condition is affecting a student's ability to keep up with their studies.

Use this template

Student name

Nombre

Apellido

Student ID

Birth date

Email

Phone number

What type of disability does the student have?

Detailed explanation of the disability

Nature of disability

Temporary Permanent Episodic / Intermittent

Expected duration of disability

Short-term Long-term Indefinite

You can add any additional functional limitation(s) related to the student's academic performance and/or provide any further information

Last date of clinical assessment

How long have you provided service to this student?

Will you continue to provide service to the student?

Yes No Not sure yet

Does the student take any medication and/or engage in any treatments that may impact their academic functioning?

Yes No

Describe the impact(s)

Based on the student's disability-related functional limitations, which accommodations or supports do you recommend to facilitate their participation in post-secondary studies?

Name of certified medical professional

Nombre

Apellido

Profession title

Phone Number

Email

Signature

Sign here

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Disability Assessment Form

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