Student Number: ____________________________

Student Name: ______________________________

Health Professional’s Report: UniAccess provides support and services for students at UWA with a disability or medical condition.  The following information will be used by the Accessibility Advisor to assist in providing the most appropriate academic support for your patient/client.  Don’t hesitate to contact one of the Accessibility Advisors via Callback line: +61 8 6488 4630  or email:  uniaccess@uwa.edu.au if you require further information. 

Consent to Release/Exchange Information

I, _____________________________ (student’s name) hereby give authority for UWA Accessibility Advisors to contact my health professional (details below), regarding documentation and the nature of my disability/medical condition, and also for my health professional to contact UWA Accessibility Advisors regarding documentation and the nature of my disability/medical condition as it pertains to my academic performance.

Student Signature: ________________________        Date: _______

Health Professional’s name: ________________________________________      Phone: _____________________
Email: __________________________________________________________       Fax: _______________________       
									
General details

Diagnosis:

Expected duration of condition:

Impact of disability or medical condition on study at UWA, including performance in exam situations
Please consider:  reading, writing, typing, cognitive functioning, sitting tolerance, energy levels, mobility and parking requirements

Effect of medication 
Please consider:  concentration and memory, mobility and stamina, visual or other systems 

Other comments

Health Professional’s Details                                                                        Practice Stamp
Signature:

Profession:
Date:

Student Number: ____________________________

Student Name: ______________________________

Statement of Limits of Use of Medical Information Collected by UniAccess
UniAccess will only use this medical information for the purpose for which it was collected.  Current documentation is required to assess whether your medical condition impacts your academic performance. The information is only used to provide reasonable adjustments to your academic program. Requests for adjustments are considered on an individual basis by taking into account institutional obligations to provide equal access to educational opportunities, documented current functional limitations, and your course requirements.  This information will not be shared with medical services or used to provide emergency medical service.  

Medical Emergencies
For immediate assistance in a Medical Emergency phone Security on 6488 2222.  Note that UWA security staff are able to provide first aid and organise an ambulance if required. For more information about UWA procedures in emergencies go to: http://www.safety.uwa.edu.au/1706946.  

Emergency Evacuation
If you may require assistance to evacuate from a university building, please make yourself familiar with the ‘People with specific needs: Responsibility of the person with a disability’ outlined here:  http://www.safety.uwa.edu.au/1706946

Release of Information and Limits of Confidentiality
Confidentiality of your medical information is maintained within the UniAccess service. Medical information about a student is only released with the written consent of the student with the following exceptions:  information may be disclosed without client consent where there is a clear danger to the client or others or there is a legal obligation to do so by court subpoena, search warrant or legislated requirement. 

I have read the above terms of the service and agree to these conditions. 
Student Signature________________________
Date  __________________________________