Section A: Student information, consents and declarations
The student supplies their school, Social Insurance Number, student number, Ontario Education Number if they have one, and contact details, and signs the required consents in Part 1. Those consents let you send the health information to the ministry and the school, and let either contact you about unclear or illegible answers, but only about this form. An optional Part 2 consent lets the school's accessibility office see the disability details, where the school has such an office.
Section B: Verification of patient's disability
Begin with the patient's first name, last name and date of birth. The ministry weighs whether the disability meets the federal definitions and causes functional limitations that restrict the daily activities needed for postsecondary study. Give clear statements on the nature of the disability, the limitations and the educational barriers, and continue on official letterhead if you run out of space. Parts 1 to 5 and 7 must be fully answered; Part 6 affects grant eligibility rather than verification.
Part 1: Physician or regulated health care professional information
Provide your name, telephone number and specialty, and tick each provider type that applies, such as nurse practitioner, optometrist, physiotherapist, neurologist or psychologist. The licence chart needs your Canadian provincial or territorial licence number and address, plus an office stamp; with no stamp, sign your letterhead and attach it. The form will not be accepted if the chart is incomplete and has neither a stamp nor signed letterhead.
Part 2: Patient's disability status
Part 2 holds two Yes/No questions. Permanent means the impairment or functional limitation restricts the activities needed to study at a postsecondary level or join the labour force and is expected to last for the student's expected life. Persistent or prolonged means the same restriction has lasted, or is expected to last, at least 12 months but not for life. Answering No to both lets you skip Parts 3 to 6 and sign Part 7, with Parts 1, 2 and 7 complete.
Part 3: Nature of patient's disability
Check every category that fits: acquired brain injury, ADD/ADHD, autism spectrum disorder, chronic health conditions such as Crohn's disease, epilepsy, chronic pain or a heart condition, deaf or hard of hearing, functional or mobility impairments, learning disability, mental health impairment, visual impairment, or another disability you name. For a learning disability, record whether a registered psychologist, psychological associate or neuropsychologist did a psycho-educational assessment, its most recent date, and whether a learning disability was confirmed.
Part 4: Mobility/movement and/or sensory impacts
Select the physical and sensory impacts that apply, such as ambulation, standing, sitting, stair climbing, lifting or reaching, dexterity, low vision after correction, legal blindness or hearing loss, then describe them. Part 6 asks for recommendations based on these functional limitations, so a specific description here backs up what you recommend later. Tick "No mobility/movement or sensory impacts" if none apply, so the part is not left blank.
Part 5: Cognitive and/or behavioural impacts
Select cognitive and behavioural impacts: attention and concentration, memory, verbal or written information processing, stress management, communication, organization and time management, social interactions or other, and describe them in the box. If none apply, tick "No cognitive or behavioural impacts". Avoid vague terms: Section B specifically warns against phrases such as "suggests", "is indicative of" and "undisclosed".
Part 6: Recommended accommodations or supports for postsecondary studies
Based on the student's functional limitations, tick each recommendation: reduced course load, specialized equipment or specialized services, specifying what is needed, or None. If approved, the BSWD and CSG-DSE may help pay for the services and equipment you list here, though funding isn't guaranteed. A blank Part 6 doesn't stop disability verification, but the student may not be eligible for the BSWD or CSG-DSE.
Part 7: 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 has the functional limitations and educational barriers indicated. For an electronic signature, use Fill & Sign or a Digital ID in Adobe Reader or another PDF program. Give the completed form and any attachments back to the student, who submits it.