Accessibility Testing

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This is Jess's play accessibility form

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

This section to be completed by doctor.

Last Name

First Name

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Any other concerns not mentioned above that we should be aware of?

Condition

Medication

Dosage

Directions

Additional Comments e.g., possible reactions, consequences of missing medication, etc.

Medication, food or other

Describe Reaction

Treatment

Name of Doctor

Specialty

Address

City

Postal Code

Office Phone Number

Fax Number

Alternate Number

Please attach a copy of your child/youth's immunization record.

Drag files here or use the button below. Remove File

Remove File

Select File

4-6 years of age

Date of Immunization

Date of Immunization

MM/DD/YYYY

11 year of age (Grade 6)

Date of Immunization

MM/DD/YYYY

Date of Immunization

MM/DD/YYYY

Date of Immunization

MM/DD/YYYY

Date of Immunization

MM/DD/YYYY

14 year of age (Grade 9)

Date of Immunization

MM/DD/YYYY

Date of Immunization

MM/DD/YYYY

Date of Immunization

MM/DD/YYYY

Other Vaccinations

Tuberculosis Testing (Required)

Other (describe)

Date of ImmunizationMM/DD/YYYY

Doctor Name

Date Signed

MM/DD/YYYY

Doctors's Signature

0114641f6fa18479e9f46b0d723431fc89af7d02

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