Section A: Student information, consents and declarations
The student enters their school, Social Insurance Number, student number, Ontario Education Number if assigned, and contact details, then signs Part 1, the required consents. These authorize you to release the requested health information to the ministry and the school, and allow either to contact you if your answers are unclear or illegible, limited to this form. Part 2 is an optional consent to share the disability information with the school's accessibility services office. The student then sends you all pages of Section B.
Section B: Verification of patient's disability
Enter the patient's first name, last name and date of birth. Eligibility depends partly on whether the disability meets the federal definitions of permanent or persistent or prolonged disability and causes functional limitations that restrict the daily activities needed for postsecondary study. Write clear statements about the nature of the disability, the functional limitations and the educational barriers. If you need more room, continue on your official letterhead and attach it. Every question and field in Parts 1 to 6 must be answered.
Part 1: Physician or regulated health care professional information
Give your name, telephone number and specialty, and tick every provider type that applies, from audiologist or speech-language pathologist to family physician, psychiatrist, psychologist or rheumatologist. The chart below needs your Canadian provincial or territorial licence number and address, plus your office stamp. If you have no stamp, sign your letterhead and attach it. OSAP will not accept the form if this chart is incomplete and there is no stamp or signed letterhead.
Part 2: Patient's disability status
Answer two Yes/No questions. A permanent disability is any physical, mental, intellectual, cognitive, learning, communication or sensory impairment, or functional limitation, that restricts the daily activities needed to study at a postsecondary level or take part in the labour force and is expected to remain for the student's expected life. A persistent or prolonged disability causes the same restriction and has lasted, or is expected to last, at least 12 months, but is not expected to be lifelong.
Part 3: Nature of patient's disability
Tick every category that applies: acquired brain injury, ADD/ADHD, autism spectrum disorder, chronic health or medical disability, deafened, deaf or hard of hearing, functional or mobility impairment, learning disability, mental health impairment, visual impairment, or another disability you specify without vague terms. For a learning disability, say whether a registered psychologist, psychological associate or neuropsychologist has done a psycho-educational assessment, give the date of the most recent one, and state whether it confirmed a learning disability.
Part 4: Mobility/movement and/or sensory impacts
Tick each impact that applies: ambulation, standing, sitting, stair climbing, lifting, carrying or reaching, grasping, gripping or dexterity, low vision after correction, legal blindness, hearing loss, or other sensory impacts you specify. Then describe the impacts in the box, tied to the educational barriers they create. If there are none, tick "No mobility/movement or sensory impacts" instead of leaving the part empty, because a blank field means the student will not be considered disabled for OSAP purposes.
Part 5: Cognitive and/or behavioural impacts
Tick each cognitive or behavioural impact: attention and concentration, memory, verbal or written information processing, stress management, communication, organization and time management, social interactions, or other. Describe the impacts in the box, or tick "No cognitive or behavioural impacts" when none apply. If the student signed the optional Part 2 consent in Section A, the school's accessibility services office can use this information when discussing supports, services and accommodations with them.
Part 6: Declaration of physician or regulated health care professional
Sign and date to certify that the information is accurate and, if you answered Yes in Part 2, that the student experiences the functional limitations and educational barriers indicated. On a fillable copy, add your signature with the Fill & Sign feature or a Digital ID in Adobe Reader or another PDF program. Return the form and any letterhead pages to the student, who is responsible for submitting it.