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 or phone, 705.474.3450 ext. 4362

Contact Information
Permission to leave a voicemail:
Program of Study
Are you applying as a...
Does your program have a placement requirement (e.g. nursing, education, etc.) for which you may require accommodations?
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
Do you have a formal assessment/diagnosis of the disability/disabilities which you have identified above?
Please remember to send us a copy of your assessment/documentation when you return this form.
How did you hear about our services? Please select all that apply:

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.