Random SAC Student #

REQUEST FOR DISCUSSION AT STUDENT ACCOMMODATION COMMITTEE

SAC Student: MD

Date of SAC meeting :

ÿ  New request

ÿ  Amendment of existing accommodation

ÿ  Renew existing accommodation for 2013-2014 academic year

Reason for accommodation request:

Non academic: / Academic:
1.  Religious (e.g. time off, space for prayer..) / 2.  Learning disability
3.  Physical accessibility / 4.  ADHD / ADD
5.  Physical need (e.g. space/time for breastfeeding, ) / 6.  Mental health disability
·  Other: / 7.  Physical disability
o  Temporary
o  Permanent
Pre-clerkship / Clerkship
8.  Classroom / 9.  Classroom
10.  Written examination / 11.  Written examination
12.  Practical Examination / 13.  OSCE examination
·  OSCE examination / 14.  Clinical rotation
15.  Computer-based task / o  On-call Schedule
·  Homework / ·  Rotation schedule / site
·  Other: / ·  Other:

ÿ  Accommodation request: Date:

ÿ  Meeting with SAC Counsellor: Date:

ÿ  Meeting with SAO assistant Dean: Date:

ÿ  Other assessments: Date:

ÿ  Assessed by Wellness Program Date:

ÿ  Followed by PHP (last assessment) Date:

Documentation supplied:

ÿ  Assessment by SASS: Date:

ÿ  Psycho-educational assessment Date:

ÿ  Expert medical opinion : Date:

ÿ  Other: specify: Date:

Goal(s) of Accommodation / Functional limitation / Accommodation suggested
S=same as previously granted by PEC
N=new request
Classroom
Written examination
Practical examination
OSCE examination

*****FOR STUDENT A CCOMMODATION COMMITTEE USE ONLY ****

Date / Accommodation
Review by SAC executive / Suggested changes:
Full SAC committee presentation / ÿ  Additional information required
ÿ  Revision of accommodation request necessary
ÿ  Accommodation approved by SAC
Details of accommodation, for submission to Promotions Executive Committee: (as stated in SAC committee minutes)
(cut and paste from minutes)
Follow up needed / ÿ  Student Affairs Assistant Dean
ÿ  Academic Advisor
ÿ  Faculty Wellness
ÿ  Physician Health Program OMA PHP
ÿ  Student Affairs Counsellor
ÿ  Other
Submitted to PEC / Date:
Approved by PEC / Date: / Details of approved accommodation: (as per communication from PEC)
(cut and paste from PEC decision)

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