Fillable Printable MEDICAL ASSESSMENT FORM For Students with Permanent Disabilities - Nova Scotia

MEDICAL ASSESSMENT FORM For Students with Permanent Disabilities - Nova Scotia

M2012

Instructions for Completing

MEDICAL ASSESSMENT FORM

For Students with Permanent Disabilities

Nova Scotia Student Assistance requires this form to be completed by a qualified medical assessor in order to verify

the applicant’s permanent disability and to determine eligibility for disability-related financial grants and disability training

related goods and services, while attending post-secondary education. Individuals who meet the disability criteria

become part of the Department of Advanced Education Labour Market Agreement for Persons with Disabilities

(LMAPD) program administered through the Post-Secondary Disability Services Division.

“Permanent disability” means a functional limitation caused by a physical or mental impairment that restricts the ability

of a person to perform the daily activities necessary to participate in studies at a post-secondary school level or the

labour force and is expected to remain with the person for the person’s expected life.

Note: Not all medical conditions are considered permanent disabilities for the purposes of these grants.

APPLICANT

Complete the Consent Form on page 1, Section A and Section B on page 2.

Have the sections relating to your disability completed by the appropriate qualified medical assessor. For

example, if you are visually impaired, your form should be completed by an Ophthalmologist or Optometrist. If

you have a hearing impairment, your form should be completed by an Audiologist. Your limitations and barriers

to your program of study must be clearly identified.

If you have a Learning Disability, you must attach a current Psycho-Educational Assessment, completed

within the last 5 years by a Registered Psychologist and submit it with the signed Consent Form (page 1) and

completed Section A and B (page 2). Any other supporting documentation in reference to your learning needs

would also be helpful.

If you have ADD/ADHD, the medical documentation must include a comprehensive report that includes the

following information: diagnosis according to the DSM IV Criteria, year of diagnosis, in-depth background

history, diagnostic tools used including information from collateral informants used for diagnostic purposes,

evidence of impairment affecting various environments, medication used and recommendations for

overcoming limitations/barriers. Any other supporting documentation in reference to your learning needs along

with copies of any previous Psycho-Educational Assessments would be beneficial.

If you previously did not meet the disability criteria either because your documentation was not current or there

was insufficient information provided to support your application, you must provide additional or current

information from your medical assessor that clearly outlines the limitations and barriers that your disability will

present while participating in studies at a post-secondary institution. Any previous documentation sent to our

office is on file.

MEDICAL ASSESSOR

This Medical Assessment Form will be used as one of the criteria to determine this student’s eligibility to receive

Federal and/or Provincial grant funding. Please ensure the diagnosis represents this student’s permanent disability and

identifies the disability-related educational barrier(s).

Please complete the appropriate section(s) pertaining to the permanent disability diagnosis and return the form

to the student.

Medical assessors must complete all parts of Section K on pages 6 and 7, clearly describing the disability-

related educational barriers and recommended interventions.

Completed Forms are to be mailed to: Nova Scotia Student Assistance

PO Box 2290, Halifax Central

Halifax, NS B3J 3C8

Telephone: 424-8420 Toll Free in Canada 1-800-565-8420

IMPORTANT INFORMATION

Your student loan application will not be processed until all documentation has been received.

All information must be received no later than two months before your period of study ends. Funds cannot be

released after your period of study end date.

Page 1

MEDICAL ASSESSMENT FORM

For Students with Permanent Disabilities

CONSENT FOR THE COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Your personal information is protected by The Nova Scotia Freedom of Information and Protection of Privacy Act. If

you have any questions about the collection of your personal information, including health information, please contact

the Student Assistance Office of the Department of Labour and Advanced Education at 424-8420 or toll free in Canada

at 1-800-565-8420.

I understand and agree that my personal information will be used to determine and verify my eligibility for Federal and

Provincial post-secondary disability programs, to administer these programs, to enforce both the Canada Student

Loans Program and the Nova Scotia Student Assistance Program (and related legislation), and to conduct program

evaluation of disability based financial grants, goods and services. I further understand that:

1. The contents of my medical report which I submit to the Department of Labour and Advanced Education, Student

Assistance Division will be used by the Federal and Provincial governments to determine my eligibility for disability

grants, goods and/or services and repayment assistance provided to students with disabilities.

2. The Department of Labour and Advanced Education Student Assistance Division and/or the Post-Secondary

Disability Services Division may contact the medical assessor who has completed my medical and request

additional information or clarification in reference to my disability.

3. The contents of the submitted medical documentation may be shared, as necessary, with the post-secondary

institution’s disability services administrator at the campus I will be attending. The disability services administrator

may contact me to ensure that I am aware of all programs, goods and/or services that are funded through the

Federal and Provincial governments.

4. For Federal/Provincial program evaluation requirements, my personal information may be shared, as necessary,

with the Federal and Provincial governments and/or third parties contracted to do program evaluations.

5. Once disability eligibility has been established the Federal and Provincial government may use my information for

program administration and evaluation purposes. I may be contacted by Post-Secondary Disability Services or a

third party contractor, for the purposes of program evaluation. Such contact may occur while I am attending post-

secondary training and/or after I have graduated or withdrawn from post-secondary training.

6. This entire form and associated information may be shared with an appeal board, if an appeal is launched

regarding my eligibility.

Applicant’s Name (Please Print): SIN:

Social Insurance Number

Applicant’s Signature: Date:

Page 2

MEDICAL ASSESSMENT FORM

For Students with Permanent Disabilities

SECTION A: Personal Information

(Student must complete)

Last Name First Name Social Insurance Number

Address

Postal Code

Home Phone

Disability Date of Birth

day/month/year

Name of Post-Secondary Institute Program Year of Study (1 yr, 2 yr, 3 yr, etc.)

st nd rd

Please check the appropriate box:

This is my first time applying as a student with a permanent disability.

I am appealing the previous decision of my disability status and I have

provided the required information.

SECTION B:

STUDENT’S DECLARATION OF LIMITATIONS AND RESTRICTIONS (Student must complete)

Please explain how you will be restricted and/or experience a barrier in your ability to perform the daily activities to

participate in studies at the post-secondary level or in the labour force?

(If more space is required, attach additional sheets)

Take this complete form to the appropriate medical assessor for completion and submission. (Keep a copy of

the completed form for your records.)

Page 3

MEDICAL ASSESSMENT FORM

For Students with Permanent Disabilities

IMPORTANT INFORMATION FOR MEDICAL ASSESSOR

Nova Scotia Student Assistance will use this Medical Assessment Form for Students with Permanent Disabilities as one

of the criteria to determine this student’s eligibility to receive federal grant funding and/or provision of disability training

related goods and services. Please ensure that the diagnosis represents this student’s permanent disability and

details of the impact that will affect the student’s ability to meet the typical demands of a Post-Secondary

environment. W here applicable, indicate if the student’s disability necessitates a reduced course load (less than 60% of

a full course load), even with the recommended supports.

“Permanent disability” means a functional limitation caused by a physical or mental impairment that restricts

the ability of a person to perform the daily activities necessary to participate in studies at a post-secondary

school level or the labour force and is expected to remain with the person for the person’s expected life.

Note: Not all medical conditions are considered permanent disabilities for the purposes of these grants.

PLEASE COMPLETE THE APPROPRIATE SECTION THAT PERTAINS TO THE STUDENT’S DISABILITY.

NOTE: Section K on pages 6 & 7 must be completed by the medical assessor for all applicants.

Print first and last name of the student being diagnosed:

First Name: Last Name:

Section C: Physical Disability (to be completed by a Physician)

Examples: Arthritis, Spinal Cord Injury, Spina Bifida, Back Injury, etc.

Primary Diagnosis:

Year of Diagnosis/Onset:

Medication and side effects: (if applicable)

Please Complete Section K on Pages 6 & 7

Section D: Hearing Impairment

(to be completed by a Certified Audiologist)

I certify this client to be hearing impaired according to the following criteria. (Indicate appropriate description):

** Level of hearing loss in the better ear (indicate appropriate descriptions):

Part A:

Mild

Moderate

Profound

Severe

Part B:

Hearing loss interferes with student’s learning

Uses hearing aids

W ould benefit from amplification devices in an educational / vocational setting.

**A copy of a recent Audiogram must be submitted. Please Complete Section K on Pages 6 & 7

Page 4

Section E: Visual Impairment (to be completed by an Ophthalmologist or Optometrist)

I certify this client to be visually impaired according to the following criteria. (Indicate appropriate description):

A visual acuity of 6/21 (20/70), or less in the better eye after correction.

A visual field of 20 degrees or less.

Any progressive eye disease with a prognosis of becoming one of the above, in the next two years.

Near point vision for print reading of __________.

Diagnosis:

Year of Diagnosis/Onset:

Attach a copy of your most recent visual acuity report. Please Complete Section K on Pages 6 & 7

Section F: Neurological Disability (to be completed by a Neurologist, Psychiatrist or Physician)

Examples: cerebral palsy, epilepsy, multiple sclerosis, brain tumor, stroke, traumatic brain injury, etc.

Primary Diagnosis:

Year of Diagnosis/Onset:

Medication and side effects: (if applicable)

Please Complete Section K on Pages 6 & 7

Section G: ADD / ADHD (to be completed by a qualified Psychiatrist, Psychologist or Physician)

I certify this client to be ADD / ADHD according to the following criteria. (Indicate appropriate description):

Diagnosis according to DSM-IV criteria and background history is: (Please provide details in Section J)

ADHD Inattentive Type

ADHD Impulsive -Hyperactive Type

ADHD Combined Type

Please submit a comprehensive report that provides detailed information in reference to the

diagnosis and the DSM IV criteria:

This must include an in depth account of background history, year of diagnosis, diagnostic tools used including

information from collateral informants used for diagnostic purposes, evidence of impairment affecting both

social/labour force and educational environments, medication used and recommendations for overcoming

limitations/barriers.

Please advise client to submit any other supporting documentation in reference to their learning needs along with

copies of any previous Psycho-Educational Assessments if available.

Please Complete Section K on Pages 6 & 7

Page 5

Section H: Psychiatric Disability (to be completed by a Clinical Psychologist, Psychiatrist or

Physician)

Example: Mental Health Consumer

Primary Diagnosis according to DSM-IV criteria:

Year of Diagnosis/Onset:

Description of the symptoms that formed the basis of the diagnosis:

Current symptoms and levels of impairment presently experienced by the student:

Current treatment, medication and side effects:

Expected prognosis and is the condition considered permanent, chronic or temporary:

(Attach separate sheet if necessary) Please Complete Section K on Pages 6 & 7

Section I: Other Diagnosed Disabilities (to be completed by the appropriate medical assessor)

Example: Developmental Disability, Intellectual, Autism Spectrum Disorder, FAS, etc.

Primary Diagnosis:

I certify this applicant to have based on the following:

Psycho-Educational Assessment (Please include a copy)

Medical Assessment

Other - Please Specify:

Please Complete Section K on Pages 6 & 7

Section J: Other Chronic Illnesses/Syndromes - the illness/syndrome must have been persistent for

a minimum of three years and is likely to last and become permanent. (to be completed by the appropriate

medical assessor)

Examples: fibromyalgia, crohn’s, lupus, etc.

Primary Diagnosis: Year of Diagnosis/Onset:

Current symptoms and levels of impairment presently experienced by the student:

Current treatment, medication and side effects:

Expected prognosis and is the condition considered permanent, chronic or temporary:

Please Complete Section K on Pages 6 & 7

Page 6

Section K: All medical assessors must complete all parts of this section about the

applicant

Part A: Disability Determinants Please write clearly

Print First and Last Name of student being diagnosed:

Is this student a regular patient of yours?

Yes

If yes, how frequently have you met with this individual in the past 2 years?

Primary Disability Diagnosis:

Is the disability permanent?

Yes

Is the disability:

Mild

Moderate

Severe

Very Severe

Secondary Disability Diagnosis (if applicable):

Is the disability permanent?

Yes

Is the disability:

Mild

Moderate

Severe

Very Severe

Medication and Side Affects: (if applicable):

Part B: Functional Limitations Please write clearly

“Permanent disability” means a functional limitation caused by a physical or mental impairment that restricts the

ability of a person to perform the daily activities necessary to participate in studies at a post-secondary school level

or the labour force and is expected to remain with the person for the person’s expected life.

In the space below, please identify and describe in detail the daily functional impact of the disability to the

student in an educational setting and what supports can assist in reducing the limitations/barriers.

Please attach additional sheet if necessary.

Page 7

Section K: (continued)

Part C: Medical Assessor Information

I certify that the information provided on this form is accurate and the student identified in this assessment

experiences the disability-related educational barriers indicated.

Name of certifying Medical Assessor: (Please Print)

Mailing Address:

City/Town: Province: Postal Code:

Telephone:

Signature: (must be signed in ink) Date:

Day / Month / Year

Please return this form to the student or forward all pages of this form to the address

below. It would also be beneficial for the applicant to have a copy of the completed form for

their records.

Nova Scotia Student Assistance

PO Box 2290, Halifax Central

Halifax, NS B3J 3C8

Telephone: 424-8420

Toll Free in Canada 1-800-565-8420