Health Certificate - Conestoga College Health Certificate Attention Health Care Practitioner: This Health
Health Certificate - Conestoga College Health Certificate Attention Health Care Practitioner: This Health
Health Certificate - Conestoga College Health Certificate Attention Health Care Practitioner: This Health

Health Certificate - Conestoga College Health Certificate Attention Health Care Practitioner: This Health

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  • Health Certificate

    Attention Health Care Practitioner: This Health Certificate will be used as one of the criteria to determine the student's eligibility to receive academic accommodations, support services and financial supports at

    Conestoga College.

    Section A:

    To be completed by the student:

    Student Name: Last Name First Name

    Student Number:

    Date of Birth:

    Address:

    Phone Number:

    Student Consent for Release of Information:

    I , hereby authorize the Health Care Practitioner to provide the following

    information to Accessible Learning - Student Success Services, Conestoga College and, if required, to supply additional information relating to my disability. I also authorize Accessible Learning - Student Success Services, Conestoga College, to contact the Health Care Practitioner to discuss the provision of accommodations.

    Student Signature Date

    Section B:

    To be completed by a regulated Health Practitioner – please print clearly

    How long has the student been your patient? One visit Less than one year More than one year

    Duration of the student's disability (check one):

    This student's disability is: permanent temporary being monitored to determine a diagnosis

    The symptoms are: continuous recurring

    Accommodations should be put in place: permanently

    temporarily FROM TO

    Medication If the student has been prescribed medication, when is the medication most likely to impact academic functioning? Morning Afternoon Evening N/A

    Comments:

    Page 1 of 3

  • Functional Impact: Current symptoms of condition and/or medication(s) which may affect academic life

    Skills / Abilities No Mild Moderate Severe Not Impact Impact Impact Impact Sure

    Attention/concentration

    Long-term memory

    Short-term memory

    Executive functioning

    Information processing

    Ability to manage distraction- filter out distracting visual and auditory stimuli

    Judgment-anticipating the impact of one's behaviour on self and others

    PHYSICAL

    Attendance/absence from Class

    Stamina (academic)-ability to complete a full course load

    Stamina (field work)-ability to complete a 35 hr work week

    Mobility

    Gross motor

    Fine motor

    Ability to sit for sustained periods

    Ability to stand for sustained periods

    SENSORY

    Vision (best corrected) describe below:

    Hearing (best corrected) describe below:

    Speech: describe below:

    COGNITION

    Page 2 of 3

  • SOCIAL/EMOTIONAL No

    Impact Mild Impact

    Moderate Impact

    Severe Impact

    Not Sure

    Appropriate in-class and group work interactions

    Ability to perform class presentations

    Reading social cues

    Ability to manage stress during class

    Ability to manage stress during tests

    Effectively control emotions

    Other:

    Additional comments or elaboration:

    Section C:

    Certification of Health Practitioner

    Practitioner's First and Last Name

    Health Practitioner Signature

    Date

    Address or Business Stamp:

    License or Registration #

    Type of Health Practitioner: Physician Psychologist Psychiatrist Other:

    Student Consent for Disclosure of Diagnosis (to be completed by student AND Health Care Professional):

    A diagnosis is required to access some government financial aid opportunities for students with disabilities. If you wish to be eligible for these opportunities, you must provide consent for your health care professional to disclose your diagnosis here. Please note that disclosure of a diagnosis is NOT required to provide most academic accommodations.

    I , hereby authorize the health practitioner to disclose my diagnosis to Student Success Services.

    Student Signature:

    To be completed by Health Care Practitioner

    Diagnosis:

    PLEASE SUBMIT COMPLETED FORM TO: Accessible Learning - Student Success Services, Conestoga College 299 Doon Valley Drive, Room 2A103 Kitchener, ON, N2G 4M4 519-748-5220 ext. 3232, FAX 519-748-3507 accessibility@conestogac.on.ca www.studentsuccess.conestoga.on.ca

    Page 3 of 3

    www.conestogac.on.ca/accessibility-services mailto:asoffice@conestogac.on.ca

    Untitled Blank Page

    Duration of Treatment 1 Checkbox 2: Off Duration of Treatment 1 Checkbox 3: Off Duration of Treatment 1 Checkbox 1: Off Duration of Disability 3 Checkbox 3: Off Name of Health Practitioner please print: Medication Impact Checkbox 1: Off Medication Impact Checkbox 2: Off Medication Impact Checkbox 3: Off Medication Impact Checkbox 4: Off Additional Comments or Elaboration: Functional Impact Skills and Abilities Cognition Attention/Concentration Checkbox 1: Off Functional Impact Skills and Abilities Cognition Attention/Concentration Checkbox 3: Off Functional Impact Skills and Abilities Cognition Attention/Concentration Checkbox 4: Off Functional Impact Skills and Abilities Cognition Attention/Concentration Checkbox 5: Off Functional Impact Skills and Abilities Cognition Long Term Memory Checkbox 1: Off Functional Impact Skills and Abilities Cognition Long Term Memory Checkbox 3: Off Functional Impact Skills and Abilities Cognition Long Term Memory Checkbox 4: Off Functional Impact Skills and Abilities Cognition Long Term Memory Checkbox 5: Off Functional Impact Skills and Abilities Cognition Short Term Memory Checkbox 1: Off Functional Impact Skills and Abilities Cognition Short Term Memory Checkbox 3: Off Functional Impact Skills and Abilities Cognition Short Term Memory Checkbox 4: Off Functional Impact Skills and Abilities Cognition Short Term Memory Checkbox 5: Off Functional Impact Skills and Abilities Cognition Executive Functioning Checkbox 3: Off Functional Impact Skills and Abilities Cognition Executive Functioning Checkbox 4: Off Functional Impact Skills and Abilities Cognition Executive Functioning Checkbox 1: Off Functional Impact Skills and Abilities Cognition Executive Functioning Checkbox 5: Off Functional Impact Skills and Abilities Cognition Information Processing Checkbox 3: Off Functional Impact Skills and Abilities Cognition Information Processing Checkbox 4: Off Functional Impact Skills and Abilities Cognition Information Processing Checkbox 5: Off Functional Impact Skills and Abilities Cognition Information Processing Checkbox 1: Off Functional Impact Skills and Abilities Cognition Manage Distractions Checkbox 3: Off Functional Impact Skills and Abilities Cognition Manage Distractions Checkbox 4: Off Functional Impact Skills and Abilities Cognition Manage Distractions Checkbox 1: Off Functional Impact Skills and Abilities Cognition Manage Distractions Checkbox 5: Off Functional Impact Skills and Abilities Cognition Judgement Checkbox 3: Off Functional Impact Skills and Abilities Cognition Judgement Checkbox 4: Off Functional Impact Skills and Abilities Cognition Judgement Checkbox 1: Off Functional Impact Skills and Abilities Cognition Judgement Checkbox 5: Off Functional Impact Skills and Abilities Physical Class Attendance Checkbox 1: Off Functional Impact Skills and Abilities Physical Class Attendance Checkbox 3: Off Functional Impact Skills and Abilities Physical Class Attendance Checkbox 4: Off Functional Impact Skills and Abilities Physical Class Attendance Checkbox 5: Off Functional Impact Skills and Abilities Physical Stamina Academic Checkbox 5: Off Functional Impact Skills and Abilities Physical Stamina Academic Checkbox 4: Off Functional Impact Skills and Abilities Physical Stamina Academic Checkbox 3: Off Functional Impact Skills and Abilities Physical Stamina Academic Checkbox 1: Off Functional Impact Skills and Abilities Physical Stamina Field Work Checkbox 3: Off Functional Impact Skills and Abilities Physical Stamina Field Work Checkbox 4: Off Functional Impact Skills and Abilities Physical Stamina Field Work Checkbox 1: Off Functional Impact Skills and Abilities Physical Stamina Field Work Checkbox 5: Off Functional Impact Skills and Abilities Physical Mobility Checkbox 3: Off Functional Impact Skills and Abilities Physical Mobility Checkbox 4: Off Functional Impact Skills and Abilities Physical Mobility Checkbox 5: Off Functional Impact Skills and Abilities Physical Mobility Checkbox 1: Off Functional Impact Skills and Abilities Physical Gross Motor Checkbox 3: Off Functional Impact Skills and Abilities Physical Gross Motor Checkbox 4: Off Functional Impact Skills and Abilities Physical Gross Motor Checkbox 1: Off Functional Impact Skills and Abilities Physical Gross Motor Checkbox 5: Off Functional Impact Skills and Abilities Physical Fine Motor Checkbox 1: Off Functional Impact Skills and Abilities Physical Fine Motor Checkbox 3: Off Functional Impact Skills and Abilities Physical Fine Motor Checkbox 4: Off Functional Impact Skills and Abilities Physical Fine Motor Checkbox 5: Off Functional Impact Skills and Abilities Physical Ability Sustained Sitting Checkbox 2: Off Functional Impact Skills and Abilities Physical Ability Sustained Sitting Checkbox 3: Off Functional Impact Skills and Abilities Physical Ability Sustained Sitting Checkbox 4: Off Functional Impact Skills and Abilities Physical Ability Sustained Sitting Checkbox 1: Off Functional Impact Skills and Abilities Physical Ability Sustained Sitting Checkbox 5: Off Functional Impact Skills and Abilities Physical Ability Sustained Standing Checkbox 2: Off Functional Impact Skills and Abilities Physical Ability Sustained Standing