Health Professional Recommendation Form

In accordance with the Ontario Human Rights Code, the College will consider all accommodation requests received from any Candidate, Applicant (including PLAR Applicant), or Registrant to ensure they are provided with a fair opportunity to complete College requirements. You have been given access to this form as a Candidate/Applicant/Registrant who has requested an accommodation due to a disability, as defined in s. 10(1) of the Ontario Human Rights Code or a pregnancy-related condition or issue, as defined in the College’s Examination Accommodations Policy.

 

INSTRUCTIONS

This form must be completed by a registered Regulated Health Professional. Please attach any additional information (where additional space or supporting documentation is required) as appendices to this form.


Regulated Health Professional means a member of a Canadian self-governing health profession as established pursuant to Schedule I of the Regulated Health Professions Act, 1991 or equivalent provincial legislation outside of Ontario who is qualified to make an assessment or diagnosis of a condition.

 
 

A. PERSON FOR WHOM THIS ACCOMMODATION INFORMATION APPLIES

In this section, please enter the details of the individual seeking an accommodation and has requested that you complete this form.

 
 

Please provide their given (first) name.

 

Please provide their middle name.

 

Please provide their family (last) name.

 
 

B. REGULATED HEALTH PROFESSIONAL INFORMATION

Please provide the following information about yourself.

 

Please provide your first (given) and last (family) name.

 

Please provide your license/certificate number.

 

Please provide the street number and street name, or postal box number for you mailing address.

 

Please provide the city, town or community for your address.

 

Please select the Province or Territory for your mailing address.

 

Please provide the postal code for your mailing address.   

 

Please provide a telephone number where the College can reach you during regular business hours. To adjust the country, please use the arrow key to select the correct flag.

Phone
 

Please provide an email address to which the College may send you communication or information.

 

Please identify the health regulatory College with which you are regulated.

 

Please describe your professional qualifications, including your area(s) of practice and any specialties, and any experience you have assessing or recommending exam accommodations.

 
 
 

You may upload additional information below.

Drop your files here
 
 

I confirm that my professional designation and regulated scope of practise, as authorized to me through registration with the above noted regulatory body in Section B, allows me to diagnose and/or assess the disability in question or the pregnancy-related condition or issue. I further understand that the College may verify this information with my regulatory body

 

The information that I have provided is true and accurate to the best of my abilities.

 

By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.

 

Please enter the date that you are completing this form.

 
yyyy-mm-dd
 
 

E. COPY OF SUBMISSION

Below is a check box to enable you to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address. This will enable the on-line system to send you a copy of the information that you have provided to the College.