Applicants are required to complete the attached “Consent To Release Medical Information”before taking this form to a Health Care Professional.
The “Verification of Disability/Impairment Form” must be completed by a qualified Health Care Professional who knows the applicant well enough to comment on his/her disability or impairment and the difficulties that he/she may have in finding or keeping a job.
The following qualified Health Care Professionals may complete this form:
The following applicants are not required to complete this form:
The following applicants may not be required to complete this form. Please contact your ODSP office to inquire:
The applicant must return both the “Verification of Disability/Impairment” form and the “Consent to Release Medical Information” form together with the “Application for Employment Supports” form to the contact listed below.
am applying to receive Employment Supports under the Ontario Disability Support Program Act, 1997, from the Ministry of Community and Social Services of the Province of Ontario.
Name of Health Care Professional (please print)
to disclose to representatives of the Ministry of Community and Social Services the medical and related information requested in the attached Verification of Disability/Impairment Form for the purpose of verifying my initial and on-going eligibility for ODSP Employment Supports.
In the event that I request a review of any decisions made by the Ministry regarding my initial or on-going eligibility for Employment Supports under the Ontario Disability Supports Program Act, 1997, I acknowledge that any or all of the information provided pursuant to this consent may be released to the Dispute Resolution Committee.
I fully understand the nature and purpose of this consent and give my consent and authorization voluntarily.
Signature of Applicant *
Name of Witness (please print)
**
Signature of Witness
** Please have your signature witnessed by anyone over the age of 18 years.
* In situations where the applicant is unable to provide consent in writing, by reason of physical or mental disability, the consent of the trustee, legal guardian or, if there is no legal guardian, the next of kin (with the applicant's verbal consent), will suffice.
To be Completed by the Applicant
Please print the following personal information:
Mr. Ms. Mrs.
Last Name
First Name
Date of Birth Day Month Year
Address
City Postal Code
Home Telephone / TTY ( Enter area code ) Enter telephone number 7 digits Work Telephone ( Enter area code ) Enter telephone number 7 digits Ext.
To be Completed by the Health Care Professional
Applicants may be eligible to receive Employment Supports if they meet certain conditions including having a physical or mental impairment that is continuous or recurrent and expected to last one year or more, and that presents a substantial barrier to competitive employment.
Please complete and sign this report and return it to your patient/client.
The information will be used in connection with your patient's/client's application for ODSP Employment Supports. The purpose of ODSP Employment Supports is to help people with disabilities prepare for, obtain, and maintain competitive employment.
The Ministry of Community and Social Services is not responsible for any payment related to the completion of this form.
1. Please describe the nature of the applicant's disability(ies) or impairments(s):
Secondary disabilities (if any):
2. Is/are the disability(ies) or impairment(s) continuous or
recurrent/sporadic:
Continuous Recurrent/sporadic
If recurrent/sporadic, please describe:
3. Is/are the disability(ies) or impairments(s) likely to continue for:
Less than 1 year 1 year or more
4. Please describe how the disability(ies) or impairment(s) present(s) a substantial barrier, if any, to employment (e.g. preparing for, obtaining or maintaining employment):
5. Are there any medical or other conditions/requirements that would
prevent participation in part-time or full-time training or employment?
Yes No
If yes, please explain
6. Additional Comments:
Name of Health Care Professional (please print)
City Postal Code
Telephone Number ( Enter area code ) Enter telephone number 7 digits Fax Number ( Enter area code ) Enter fax number 7 digits
Signature of Health Care Professional
(Freedom of Information and Protection of Privacy Act)
The information is collected under the legal authority of the Ontario Disability Support Program Act, S. O. 1997, c.25, Schedule B, sections 32 and 33 for the purpose of providing employment supports to enable persons with disabilities to obtain and maintain employment. For more information contact at , in your local ODSP office.
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