Breadcrumb Home Accessibility Services Self-Identification Form Accessibility Services Self-Identification Form If you are a student with a permanent or temporary disability and you may require academic accommodations to support your learning at Nipissing, please complete and submit the following form as soon as possible. Note: Upon receiving this completed form, Student Accessibility Services will contact you to begin the intake process. If you have any questions regarding this self-identification process or general inquires, please contact Student Accessibility Services by email, sas@nipissingu.ca or phone, 705.474.3450 ext. 4362 Contact Information Name I Use First Name Last Name Student ID # Pronoun Address Address Address 2 City/Town State/Province ZIP/Postal Code Telephone # Permission to leave a voicemail: Yes No Email Address Nipissing Email Address Program of Study Degree Program / Major Select your ProgramAncient StudiesAnthropologyBiologyBusiness AdministrationChild and Family StudiesCommerceComputer ScienceCriminal JusticeData ScienceEconomicsEducation (Consecutive)English StudiesEnvironment and Physical GeographyEnvironmental Biology and TechnologyEnvironmental GeographyEnvironmental ScienceFine ArtsGender Equality and Social JusticeGeographyHistoryIndigenous StudiesLiberal ArtsLiberal ScienceMathematicsNursingPhilosophyPhysical and Health EducationPolitical SciencePsychologyReligions and CulturesSocial Welfare and Social DevelopmentSocial WorkSociologyMaster of Arts in HistoryMaster of Arts in Sociology - Applied Social ResearchMaster of EducationMasters of Environmental Science/StudiesMaster of Science in KinesiologyMaster of Science in MathematicsPhD in Education (Educational Sustainability)Undeclared / UndecidedOther Campus - Select -North Bay CampusDistance / Online Are you applying as a... High school student College/University Transfer Student Mature Student Distance Education Student Current student Does your program have a placement requirement (e.g. nursing, education, etc.) for which you may require accommodations? Yes, my program has a placement requirement which I may require accommodations. No, my program does not have a placement requirement. Disability-Related Funding We encourage students with disabilities to apply for OSAP as they may be eligible for additional funding to help cover disability related educational costs. Click here for more information about OSAP for students with disabilities and to apply. Have you applied for OSAP this coming year? Yes, I have applied for OSAP this coming year. No, I have not applied for OSAP this coming year. Have you self-identified as a student with a disability on your OSAP application? Yes No Has your health care provider completed your OSAP Disability Verification Form? Yes No Have you submitted your OSAP Disability Verification Form to OSAP? Yes No Will you be eligible for OSAP this year? Yes, I will be eligible for OSAP this year. No, I will not be eligible for OSAP this year. Not sure Disability Information Students requesting academic accommodation are required to provide Student Accessibility Services with current documentation from a regulated health care professional who is licensed to diagnose your disability or health condition. Specific documentation requirements will depend on the nature of a student’s disability. Click here to learn more about the required documentation for the following disabilities. Please select your identified disability/disabilities Acquired Brain Injury Attention Deficit-Hyperactive Disorder Physical / Medical Condition Deaf / Deafened / Hard of Hearing Learning Disability Low Vision / Blind Mental Health Addiction Autism Spectrum Disorders Temporary If you selected more than one, please indicate below the nature of the disability where you feel you might need the most accommodation support: Do you have a formal assessment/diagnosis of the disability/disabilities which you have identified above? Yes, I have a formal assessment/diagnosis of the disability/disabilities for which I have identified above. No, I do not have a formal assessment/diagnosis of the disability/disabilities for which I have identified above. If Yes, what is the date of the most recent assessment/medical report? Please remember to send us a copy of your assessment/documentation when you return this form. Warning message If No, we will be in touch with you to discuss what documentation you will require. Please describe any disability-related educational services or accommodations you have used in your previous educational experiences or that you are requesting Additional comments or questions How did you hear about our services? Please select all that apply: Student/Peer Family Faculty Mental Health & Wellbeing Student Learning & Transitions Residence Staff (incl. Dons) Athletic Coach Other University Staff Promotional Material Open House/NSO High School Counsellor/Teacher Campus Health Centre Physician/Psychologist Sexual Violence Prevention and Education Other… Enter other… Were you referred to Student Accessibility Services by another Nipissing University department? Yes No Which department referred you? Protection of Privacy: The information on this form is collected under the authority of the Nipissing University Act, 1992. It is related to and needed by the University to provide services and support disability-related accommodation requests for students with disabilities. The information will be used by employees of the Counselling and Student Accessibility Services Office and will not be disclosed to any third party without your written consent. If you have any questions about the collection, use and disclosure of this information, please contact the Manager of Student Accessibility Services, Nipissing University, 100 College Drive, North Bay ON P1B 8L7, 705.474.3450 ext. 4097.
