CONFIDENTIAL DIAGNOSITIC VERIFICATION FORM
Academic accommodations are provided by the University of Regina for students with short-term and
permanent disabilities. Students receive accommodations based on documentation received from their
doctor or other certified professional. Students with learning disabilities typically receive accommodations
based on a psycho-educational assessment completed by a registered psychologist.
Completed forms may be returned to the University of Regina's
Centre for Student Accessibility by fax (306-585-5650), mail, or in person
Last Name: First Name: UofR Student ID Number:
Address: City/Town: Province: Postal Code:
E-mail: Date of Birth:
STUDENT AUTHORIZATION FOR RELEASE OF INFORMATION:
I authorize the release of my disability information on this form to the Centre for Student Accessibility (CSA).
Student Signature: Date:
Witness Signature: Witness Printed Name: