Form NWT9008 "Disability Assessment Form" - Northwest Territories, Canada

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NWT Student Financial Assistance
DISABILITY ASSESSMENT FORM
For the purpose of the Study Grant(s) for Students with Permanent Disabilities, “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 level and that is expected to remain
with the person for the person’s life.
Student Instructions:
1. If you are requesting the Study Grant(s) for Students with Permanent Disabilities, this form is to be
completed by a certifying medical professional.
2. Complete Section 1 then forward the form to your certifying medical professional for completion of Section
2.
3. Upon completing this form, the certifying medical professional should return the form to you.
4. Any fees charged by your certifying medical professional in completing this form are your responsibility and
will not be reimbursed by the Department of Education, Culture and Employment.
Certifying Medical Professional Instructions:
1. Upon completion of this form, please return it to the student or address below.
2. Any fees charged for the completion of this form are the responsibility of the student and will not be
reimbursed by the Department of Education, Culture and Employment.
3. The Study Grant(s) for Students with Permanent Disabilities helps with the education-related costs for a
permanent disability that limits a student from fully participating in postsecondary studies. This Grant may
be used to cover exceptional educational expenses such as the cost of a tutor, an interpreter (oral or sign),
note-taker, attendant care or special equipment.
Contact/Mailing Information:
NWT Student Financial Assistance
Income Security Programs Division
Department of Education, Culture and Employment
Government of Northwest Territories
Box 1320
Yellowknife, NT X1A 2L9
Phone: 1-867-767-9355 | 1-800-661-0793
Fax:
1-867-873-0336 | 1-800-661-0893
Email: nwtsfa@gov.nt.ca
PAGE 1 OF 2
NWT9008/0617
NWT Student Financial Assistance
DISABILITY ASSESSMENT FORM
For the purpose of the Study Grant(s) for Students with Permanent Disabilities, “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 level and that is expected to remain
with the person for the person’s life.
Student Instructions:
1. If you are requesting the Study Grant(s) for Students with Permanent Disabilities, this form is to be
completed by a certifying medical professional.
2. Complete Section 1 then forward the form to your certifying medical professional for completion of Section
2.
3. Upon completing this form, the certifying medical professional should return the form to you.
4. Any fees charged by your certifying medical professional in completing this form are your responsibility and
will not be reimbursed by the Department of Education, Culture and Employment.
Certifying Medical Professional Instructions:
1. Upon completion of this form, please return it to the student or address below.
2. Any fees charged for the completion of this form are the responsibility of the student and will not be
reimbursed by the Department of Education, Culture and Employment.
3. The Study Grant(s) for Students with Permanent Disabilities helps with the education-related costs for a
permanent disability that limits a student from fully participating in postsecondary studies. This Grant may
be used to cover exceptional educational expenses such as the cost of a tutor, an interpreter (oral or sign),
note-taker, attendant care or special equipment.
Contact/Mailing Information:
NWT Student Financial Assistance
Income Security Programs Division
Department of Education, Culture and Employment
Government of Northwest Territories
Box 1320
Yellowknife, NT X1A 2L9
Phone: 1-867-767-9355 | 1-800-661-0793
Fax:
1-867-873-0336 | 1-800-661-0893
Email: nwtsfa@gov.nt.ca
PAGE 1 OF 2
NWT9008/0617
NWT Student Financial Assistance
DISABILITY ASSESSMENT FORM
1. STUDENT INFORMATION
Last Name
First Name
Mailing Address
Territory/Province
City/Community
Postal Code
Telephone Number
Email Address
I consent to the release of information from the certifying medical professional to the Student Financial Assistance Program, Income Security
Programs Division, Department of Education, Culture and Employment. I understand that this information will be used to determine my eligibility
in accordance with the Student Financial Assistance Regulations.
X
Signature of Student
Date - YY/MM/DD
2. TO BE COMPLETED FULLY BY CERTIFYING MEDICAL PROFESSIONAL
Name of Certifying Medical Professional
Title
Mailing Address of Certifying Medical Professional
City/Community
Territory/Province
Postal Code
Telephone Number
Fax Number
1. What type of disability does the student have?
2. What is the diagnosis?
3. Date of diagnosis? (YY/MM/DD)
4. The disability is:
Permanent
Temporary
5. Does the disability result in a functional limitation that restricts the ability of a student to perform daily activities necessary to participate fully
in studies at a post-secondary level?
Yes
No
6. Do you recommend that the student study at a reduced level of 40% of a 100% full course load per semester?
Yes
No
7. Identify all of the student’s disability related education barriers and how it prevents them from participating in post-secondary studies:
8. Does the student require any extra educational aids related to their disability?
No
Yes, please explain:
I certify that the information provided on this form is to the best of my knowledge and accurate.
X
Signature of Certifying Medical Professional
Date - YY/MM/DD
PAGE 2 OF 2
NWT9008/0617
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