Examination Disability Information Form

APPLICANT
QUALIFIED REGULATED HEALTH PROFESSIONAL
NATURE OF DISABILITY

COPR considers a "disability" to mean:

Any degree of physical disability, infirmity, malformation or disfigurement, including:
  • epilepsy;
  • any degree of paralysis;
  • amputation;
  • lack of physical coordination;
  • blindness or visual impediment;
  • deafness or hearing impediment;
  • muteness or speech impediment; or
  • physical reliance on a service animal, wheelchair or other remedial appliance or device; or

Any of the following disabilities:
  • a developmental or intellectual disability or impairment;
  • a learning disability, or a dysfunction in one or more of the processes involved in the comprehension or use of symbols or spoken language; or
  • a mental disorder.
In your opinion, does the Applicant have a disability within the meaning of the definition above?
Is your assessment of the Applicant current (within the last year)?
CERTIFICATION BY QUALIFIED REGULATED HEALTH PROFESSIONAL

certification

I hereby certify that:
  • The Applicant has authorized and directed me to provide this form directly to COPR;
  • The Applicant has further authorized and directed me to supply additional documentation and information, if required to COPR related to the Applicant’s request for accommodation;
  • I have personally examined/assessed the Applicant;
  • I provide(d) health care services to the Applicant in respect of the Applicant’s disability;
  • I have specific training and expertise with respect to the disability for which accommodation is being requested by the Applicant;
  • I am registered, certified or licensed to practice in my field; and
  • The documentation and information I have provided is, to the best of my knowledge, true, accurate and complete.
Sign above