This form is used by the Ministry of Training, Colleges and Universities (“the ministry”) to obtain information/documentation on the student’s disability from the student’s physician or other regulated health care practitioner. Disability documentation will be used for purposes of assessing the student’s eligibility for disability-related funding available under OSAP and/or for consideration under the 30% Off Ontario Tuition grant disability-related eligibility criteria. The documentation is also required for consideration as a person with a disability under the minimum required student loan course load requirement.
Disability-related funding under OSAP includes: Ontario Bursary for Students with Disabilities, Canada Student Grant for Persons with Permanent Disabilities, and Canada Student Grant for Services and Equipment for Persons with Permanent Disabilities. This form is not an application for any of the above named funding programs. It is only a form for providing supporting documentation for disability-related eligibility criteria.
To be eligible for disability-related Canada Student Grants the student must have a permanent disability, which is defined as a functional limitation:
Documentation is usually only required once by the ministry to confirm a student’s disability. However, the ministry or the school the student is attending can ask for additional documentation at any time to confirm or re-establish disability status. The privacy of all disability documentation is protected by the ministry under the Freedom of Information and Protection of Privacy Act.
Students attending a private postsecondary school in Ontario or any postsecondary school outside of Ontario: Use this form if you do not have documentation from your physician or other regulated health care practitioner that clearly provides the following information:
Students Attending a Publicly-Assisted College or University in Ontario: It is not necessary to use this form if your school’s Office for Students with Disabilities has provided you with a disability verification form that collects the same information as described above. Please speak to the staff at your school’s Office for Students with Disabilities for more information.
Students Diagnosed with Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (ADHD): You may use this form, your school’s disability verification form, or you can provide a psycho-educational assessment or other diagnostic documentation from a registered psychologist or psychological associate, a neuropsychologist, or physician with ADD/ADHD training.
Persons diagnosed with a learning disability do not need to complete this form. Instead, a psycho-educational assessment conducted by a registered psychologist or psychological associate and completed when the student was at least 18 years of age or within the past five (5) years is required.
The student must fill out Section 1 of this form (pages 3 and 4) and sign the Notice, Declarations and Consents. The student will then bring Section 2 of this form (pages 5, 6 and 7) to their physician or other regulated health care practitioner for completion.
Students attending a private postsecondary school in Ontario or any postsecondary school outside of Ontario: Submit sections 1 and 2 of this completed form to the ministry at:
Student Financial Assistance Branch Ministry of Training, Colleges and Universities 189 Red River Road, 4th Floor Thunder Bay, ON P7B 6G9
Students attending a publicly-assisted college or university in Ontario: Submit sections 1 and 2 of this completed form directly to your school’s Office for Students with Disabilities or Financial Aid Office. In all cases, the Office for Students with Disabilities will review the information provided in this form in order to verify information that is required for OSAP and 30% Off Ontario Tuition grant purposes and will communicate this information to the student’s Financial Aid Office at their school.
Students are responsible for covering any costs related to the completion of this form.
What is the name of the school you plan to attend? Social Insurance Number: Student number at your school: Ontario Education Number (OEN), if assigned to you: Last name: First name: Date of birth: (Day/Month/Year)
Street number and name, rural route, or post office box: Apartment: Street number and name, rural route, or post office box: Province or state: City, town, or post office: Postal code or zip code: Country: Area code and telephone number:
The personal information you and your physician or other regulated health care practitioner provide in connection with this form, including your Social Insurance Number (SIN), is collected and used by the ministry to determine your eligibility for disability-related OSAP and 30% Off Ontario Tuition grant funding.
Your personal information will also be used by the ministry to administer and finance OSAP and the 30% Off Ontario Tuition grant and by Employment and Social Development Canada (ESDC) to administer and finance the Canada Student Loans Program (CSLP). Your SIN will be used as a general identifier in administering OSAP. The ministry and ESDC may use other parties for any of these activities. Under agreement with ESDC, the National Student Loans Service Centre (NSLSC) uses your personal information to administer OSAP and CSLP. Under agreement with the ministry, your postsecondary school and, where authorized by the ministry, its agents who administer OSAP and its auditors use your personal information to administer OSAP and CSLP.
Administration includes: determining your eligibility for financial assistance; verifying your application and supporting documentation, including verifying financial assistance provided under any other ministry program; verifying your financial assistance or eligibility for relief from any payment, maintaining and auditing your OSAP file; assessing and collecting loans, overpayments, and repayments; enforcing the legislation set out below and your agreements with the ministry, the Ontario Student Loan Trust and ESDC; and monitoring and auditing the NSLSC and your postsecondary school or its authorized agents to ensure that they are administering the programs appropriately. In addition, administration by the ministry and ESDC includes public reporting on the administration and financing of student assistance programs and accessibility to postsecondary education; planning, delivering, evaluating and monitoring for student assistance and accessibility programs for quality and improvements in both content and delivery; conducting risk management, error management, audit and quality assessment activities; conducting investigations or inspections; and conducting policy analysis, evaluation, and research. In this context, the Ministry may use your name and contact information to contact you to participate in voluntary surveys relating to student financial assistance. Financing includes: planning, arranging or providing funding. The Ministry may use other parties for any of these activities.
The ministry collects your personal information under the authority of the Ministry of Training, Colleges and Universities Act, R.R.O. 1990, O. Reg. 268/01 and O. Reg. 118/07; s.10.1 of the Financial Administration Act; the Canada Student Financial Assistance Act, S.C. 1994, c. 28, as amended; and the Canada Student Financial Assistance Regulations, SOR 95-329, as amended and s. 266.3(4) of the Education Act. If you have any questions about the collection or use of this information contact the Director, Student Financial Assistance Branch, Ministry of Training, Colleges and Universities, PO Box 4500, 189 Red River Road, 4th Floor, Thunder Bay ON P7B 6G9.
Student’s signature: Date: Student’s Social Insurance Number:
This form will be used to determine your patient’s eligibility for Ontario Student Assistance Program (OSAP) funding for students with disabilities and disability-related eligibility for the 30% Off Ontario Tuition grant funding. Eligibility for funding is based on the functional impact of the disability on the patient’s ability to participate in a postsecondary educational environment and permanence of their disability.
Section 2 is three pages in length. All three pages must be completed. Please provide clear diagnostic statements, avoiding such terms as “suggests” or “is indicative of”. Please note any multiple diagnoses or concurrent conditions. Your patient has given consent in Section 1 of this form to the disclosure of this personal health information to the ministry and his or her postsecondary school. Once you have completed Section 2, please return all three pages to the student.
First name: Last name: Date of Birth: (Day/Month/Year)
First name: Last name:
Audiologist Chiropractor Neurologist Occupational Therapist Optometrist Ophthalmologist Physician – family Physician – Psychiatrist Physiotherapist Psychologist or Psychological Associate Rheumatologist Other Other (specify):
Licence #: 10-Digit Work telephone Number: Work telephone Number ext.
I certify that the information provided on this form is accurate and the patient identified above experiences the disability-related educational barrier(s) indicated.
Signature: Date:
Please affix official stamp of facility name and address below:
Note: If you do not have an office stamp, please sign and attach your letterhead to this form.
First Name: Last Name:
(e.g., paraplegia, quadriplegia, muscular dystrophy, cerebral palsy, spinal cord injury, spina bifida, multiple sclerosis)
Diagnosis:
Diagnosis: Visual acuity: Visual field:
Mild Moderate Severe Congenital Profound
Yes No
Diagnosis: Provide date of injury: (Day/Month/Year)
(e.g., autism, neurological disorder, Asperger’s, FASD)
Diagnosis: (please use the most recent DSM criteria):
Yes (please attach a copy of the assessment) No Unknown
(specify): Diagnosis:
The patient’s disability (or disabilities) is temporary. The patient’s disability (or disabilities) is temporary.Please indicate anticipated duration of disability:
The patient’s disability (or disabilities) is permanent with ongoing (chronic or episodic) symptoms that will restrict his/her ability to perform the daily activities necessary to fully participate in postsecondary studies or in the labour force, and the disability is expected to remain for his/her lifetime.
Ambulation Standing Sitting Stair Climbing Lifting/Carrying/Reaching Grasping/Gripping/Dexterity Please describe:
Attention and Concentration Memory Information Processing (verbal and written) Stress Management Organization and Time Management Social Interactions Communication Other Other (specify): Please describe:
Yes No If yes, please indicate any side effects (alertness, concentration, nausea) that may affect the patient’s participation in an educational environment:
The patient is advised to take a reduced course load.
The patient requires specialized computer equipment and/or software, and/or ergonomic furniture in order to participate in postsecondary education. The patient requires specialized computer equipment and/or software, and/or ergonomic furniture in order to participate in postsecondary education. Please specify:
The patient requires specialized services such as tutoring, note taking, counselling, and/or transportation in order to participate in postsecondary education. The patient requires specialized services such as tutoring, note taking, counselling, and/or transportation in order to participate in postsecondary education. Please specify:
If you require more space, please attach additional information on your letterhead.