First Name: *

Last Name: *

Birth Date: *

Student Number: *

Phone Number: * eg: Home or Mobile

Alternate Number: * eg: Home or Mobile

Email: *

Gender: * Gender... Male Female

Language: * Select a Language... English French

Faculty: * Select a faculty... Faculty of Arts Faculty of Education Faculty of Engineering Faculty of Health Sciences Faculty of Common Law Faculty of Science Faculty of Social Sciences School of Medicine School of Management Faculty of Civil Law Other

Department: *

Campus: * Select Campus... Main Campus Roger Guindon / Alta Vista Saint Paul

Year of Study: * Level... First Year Second Year Third Year Fourth Year Graduate Level

First generation: * Yes No

Are you the first in your family to receive post-secondary education

Type of Disability

Mobility impairment

Acquired brain injury

Mental health status

Physical health status

Vision impairement

Hearing impairment

Learning disability

Attention Deficit Disorder (ADD/ADHD)

Other Disability
(Please Specify):

Please describe your disability/illness and its impact on your learning and/or daily life at university:

What academic skills or abilities cause concerns related to your disability?

What are your non-academic concerns related to your disability (e.g., classroom accessibility, transport, etc.)?

Details about documentation: http://www.sass.uottawa.ca/access/students/mandatory-documentation.php

If yes, please list the adaptive measures used, including software: