Access to Students with Disabilities

1

Access to Students with Disabilities

Verification of Accommodation & Support Service Requirements

To apply for accommodations and services offered through Access to Students with Disabilities, please print this form. Once you have completed Part I: Self-Assessment and Part II: Release of Information of the application, please have Part III: Professional Verification filled in and signed by an appropriate medical or educational professional. Once the form has been completed and all relevant documentation attached, fax it to (780) 421-2546 or mail the package to the Access to Students with Disabilities Office, Athabasca University, Edmonton Learning Centre, Peace Hills Trust Tower, 1200, 10011 – 109 Street, Edmonton, Alberta, T5J 3S8. If you have questions or require assistance to complete the form, call the ASD office at (780) 497-3424 or 1-800-788-9041 ext. 3424 or e-mail us at .

Part I: Student Information & Self-Assessment

Student Information

Name:

AthabascaUniversity ID#

Are you a Graduate or Undergraduate Student?

Mailing Address:

Telephone Number (including area code):

E-mail Address:

For ASD Office Use Only

Self-Assessment

ASD and AthabascaUniversity respects the relevance of the self knowledge and experience that an individual possesses with regard to their abilities and differences. The information that you present through this self-assessment will provide an excellent foundation to enter into discussion with ASD professional staff and work collaboratively to identify reasonable accommodations that will meet your individualized needs and provide the best possible opportunity for access and success in courses at AthabascaUniversity.

Information Related to Disablement in the Educational Environment

1. Please provide a brief statement describing the nature of your permanent or temporary disability and/or medical condition and how it impacts upon you in the study environment. Include relevant information for any secondary or multiple diagnoses or on the effects of any treatments (prescription drugs or therapy) you are receiving.

1. Please identify how your medical and/or disabling condition may affect any of the following areas and the impact this may have upon your ability to pursue studies with AthabascaUniversity (please provide specific examples)
   Absenteeism

Concentration, attention and focus

Distractibility

Stamina/energy/endurance

Ability to multitask

Organization and time management

Stress or anxiety level

Physical strength/dexterity

Process auditory information

Social interaction

Resiliency to change

Communication skills

Vision

Hearing

Pain

Previous Educational Accommodations

1. Have you previously received educational accommodations or supports?

___ Yes

___ No

1. If yes, please list the accommodations or supports you received. Be sure to include course/academic accommodationssupport service (readers, scribes, aides, etc.) or learning assistance (strategists, tutors, etc.), alternate format requirements, and exam accommodations.

Available Assistive Technology

1. Please list any computer hardware or software that you have available to assist you in your studies (i.e. computer, scanner, printer, voice recognition software, screen magnification software, screen-reading software, etc.):

1. Would you like to speak with someone regarding assistive technologies that may be able to assist you in your studies?

Accommodations Requested at AthabascaUniversity

1. Please provide a preliminary list of the accommodations that you feel that you will require at AthabascaUniversity. (accommodations may include additional time to write examinations, private room to write examinations, examinations in alternate format, additional time to complete courses, etc.)

1. Do you wish to apply to be qualified as a full time student on reduced 40 percent course load? (Only students with PERMANENT disabilities)

1. Would you like to speak with someone regarding acquiring your course materials in alternate format to accommodate your disabling condition (for example materials in large print, in electronic text format, materials in audio format)

Applicant Declaration:

In making this application to the Access with Students with Disabilities Officeto request services and/or academic accommodation as a student with a disability I acknowledge that the above information presents an accurate reflection of my needs based upon my knowledge and experience of my condition.

I understand that I am responsiblefor maintaining communication with the Access to Students with Disabilities Office regarding my needs and for participating on an ongoing basis in the accommodation process. I understand that additional supporting documentation may be required to support my request for services and/or academic accommodation.

I understand that my request for services and/or academic accommodation will be reviewed with Access to Students with Disabilities Officein order to identify what is reasonable in consideration of my functional abilities and differences, treatment, symptoms, academic requirements, eligibility for funding, environment, geographic location and other available resources. Reasonable accommodations and support services will beassessed based upon individual abilitiesand differences and in consideration of academic or program requirements. As a result not all requested services and/or academic accommodations may be approved.

______

Student Signature Date

Part II: Release of Information Authorization

Student Name:

AthabascaUniversity ID#

Release of Information:

The following section must be completed by the applicant:

Please provide the name and contact information for the medical or educational professional whom you are requesting provide verification of your disablement and accommodation requirements.

Name of Professional:

Position/Title:

Professional Relationship to applicant (i.e. family physician, medical specialist, psychiatrist, educational service coordinator, etc.):

Agency/Institution:

Address:

Phone:

Fax:

E-mail:

Release of Information Waiver:

For the purpose of verifying that the self-identified differences and requested accommodations are considered valid and are directly related to a need that arises from a disabling ormedical condition, or subsequent treatment thereof, and to enable Athabasca University to properly assess what accommodations are appropriate, I authorize the professional identified above to release relevant medical or educational assessment documentation and information to Access to Students with Disabilities, Athabasca University, as well as to any other Athabasca University official or legal advisor designated by ASD, where such release is necessary to permit Athabasca University to determine whether proposed accommodations are reasonable and do not constitute an undue hardship. Typically, ASD will not provide this information to persons other than its own staff.

I further authorize any additional required communications between the Professional(s) identified above and the staff of Access to Students with Disabilities, AthabascaUniversity, to obtain more information or clarification on the disabling or medical condition (or subsequent treatment) with specific regard to the determination of an appropriate accommodation in the post-secondary environment.

I specifically authorize the professional named above to release the following documents which should then be attached to this completed application:

___psycho-educational assessment

___neuro-psychological assessment

___psychiatric reports/assessment

___audiology report/assessment

___ophthalmology report/assessment

___medical report

___educational reports

___informationregarding education accommodations

___other:

______

______

______

______

Student Signature Date

Note: This waiver is in effect until the student notifies the Access to Students with Disabilities Office, AthabascaUniversity, in writing, of the withdrawal of this authorization.

Please Note: The application and use of this authorization to release information is restricted to Access to Students with Disabilities Department and such other AthabascaUniversity officials or legal advisors as are specifically designated by ASD. Students should complete the required request forms for anydocumentation requests by other Departments or Services within AthabascaUniversity.

All information or documentation received by the ASD Office will be maintained in strictest confidence and within the guidelines of the Alberta Freedom of Information and Protection of Privacy Act and shared only with such other Athabasca University officials and legal advisors as designated by ASD and who are required to receive the information to make final assessments as to whether the accommodations sought are reasonable and do not constitute an undue hardship. Please see the FOIP statement at the bottom of this Form for further information.

PART III: Professional Verification

Student Name:

AthabascaUniversity ID#

The following section is to be completed by the professional that has been designated by the applicant in Part 2 of the applicant. (Make additional copies if more than one professional is designated.)

Name:

Position/Title:

Credentials:

Response to the following questions will enable ASD to work in collaboration with the applicant to determine the best possible accommodation solutions. The information that is collected will also assist ASD staff to identify funding and other resource options available to students with disabilities for which this applicant may be eligible. Please attach any assessments or documents that have been authorized for release by the applicant.

ASD Eligibility criteria: Enrolled or prospective students with functional differences resulting from disabilities or medical conditions that are sensory, learning, physical/mobility, neurological, psychological, permanent or chronic disabilities or medical conditions, or injuries that are temporary in nature and necessitate accommodation in the education environment are eligible for ASD services.

1. In your professional opinion does this applicant meet the eligibility criteria to receive service or accommodation?

___ Yes

___ No

1. Do you consider this individual’s disability/condition to be:

___ Permanent

___ Temporary

If the condition is temporary, by what date would you expect sufficient recovery to eliminate the need for accommodation? ______

1. Based on the applicant’s diagnosis, would you expect that this individuals accommodation requirements will:

___ increase over time due the progressive nature of the condition

___ remain generally stable over time

___ potentially fluctuate with regard to symptoms, altering bio-chemical levels, or

the disease pathology.

1. At the present time, would you recommend this student should proceed with a course load:

___ part time studies (20 – 40% course load)

___ student should be considered full-time with a reduced course load

(40% course load)

___ full time studies (60 – 100% course load)

Professional Statements to Verify Need for Accommodations

Please advise as to whether, in your opinion, the Applicant has any disabilities either as self identified or otherwise. Please also comment on what, if any, educational accommodations you consider to be necessary and directly arising from the disabling or medical condition you have verified or any subsequent treatment thereof. Please also indicate whether you believe the Applicant would benefit from the use of any specific assistive technologies (e.g. voice recognition, text to voice, computer, etc.) to assist the Applicant in accessing or successfully completing courses. If so, could you identify the type of technologies that may be of benefit?

The information contained in this professional statement are within my professional expertise and knowledge that I have of this Applicant

______

Signature of ProfessionalDate

Please return completed form to:

Attention: Professional Services Coordinator

Access to Students with Disabilities

AthabascaUniversityEdmonton

Peace Hills Trust Tower
1200, 10011 – 109 Street
Edmonton, ABT5J 3S8

The personal information collected on this form will be used to verify the presence of a disabling or medical condition to determine eligibility for ASD services and accommodations. This information is collected under the authority of section 33 ( c ) of the Alberta Freedom of Information and Protection of Privacy Act. If you have any questions about the collection and use of this information, contact the Coordinator, Access to Students with Disabilities, Athabasca University Edmonton,Peace Hills Trust Tower, 1200, 10011 – 109 Street , Edmonton, Alberta, T5J 3S8, (780) 497-3424 or 1-800-788-9041 ext. 3424.