The NWT Department of Education, Culture and Employment uses Form D to confirm a disability for the Income Assistance for Seniors and Persons with Disabilities program. The practitioner rates the impairment as permanent, long-term, episodic or short-term and describes how it restricts daily living and the ability to meet basic financial needs. The form goes directly from the practitioner to the regional ECE Service Centre.
A medical practitioner or nurse practitioner completes Section 2, initialling each page and certifying with their registration number. A registered nurse licensed in the NWT may complete Section 3 only when there is no access to a medical practitioner or nurse practitioner in the next 3 months, and the applicant completes Section 1.
Download the current version from the source each time; forms change without notice.
Form D - Disability Assessment
Formulaire D - Évaluation de l'incapacité
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Yes, but only in Section 3 and only when the person has no access to a medical practitioner or nurse practitioner in the next 3 months. The nurse must be licensed in the NWT, base the answers on the patient chart, and certify that a physician or nurse practitioner cannot complete the form.
Yes. ECE publishes a fillable French version, Formulaire D, Évaluation de l'incapacité, alongside the English form NWT9386. Both have the same sections: the applicant's information and consent, the medical or nurse practitioner's assessment, and the registered nurse's alternative assessment.
The form defines episodic as a prolonged, lifelong condition with unpredictable episodes of illness and disability, often followed by periods of wellness. Episodic or recurrent is a separate choice from long-term, which means the impairment affects the person continuously for the next 12 months.