Common menu bar
Breadcrumb
Appendix 2 - Questionnaires to gather information on functional limitations
When determining assessment accommodations, a good understanding of the nature and extent of the applicant's functional limitations is essential. You will find in this appendix four questionnaires designed to help you gather such information in part.
- The first questionnaire can be used for persons who have limitation related to mobility or agility, mental health, chronic illnesses, temporary conditions or environmental sensitivities (such as allergies).
- The second questionnaire can be used for persons who have visual limitations.
- The third questionnaire can be use for persons who have hearing limitations.
- The fourth questionnaire can be used for persons who have learning disabilities or Attention Deficit Hyperactivity Disorder.
Information on functional limitations
This information is required to determine assessment accommodations that might be necessary in an appointment process within the Public Service of Canada.
1. Please describe the functional limitations you experience presently (for example: reduced mobility, manual dexterity, anxiety, lack of concentration, pain, fatigue, etc)
2. How do the above functional limitations impact the following areas?
- reading
- writing
- speaking
- hearing
- concentration or attention
3. Is your condition stable?
- Yes
- No
Is your condition episodic in nature?
- Yes
- No
Please describe:
4. Do you take medication that may affect your performance in an assessment situation?
- Yes
- No
Please describe the current effect of medication on:
- your speed of information processing
- your concentration
- other
5. What is the most appropriate time of day for assessment? (Specify hour if necessairy)
- Morning
- Afternoon
6. Is fatigue or pain a factor when undergoing assessment?
- A great deal
- Some
- None
Must you frequently stretch or change position?
- Yes
- No
How often do you require breaks? Every:
- x minutes
- x hours
7. Are you usually using an adaptive technology?
- Yes
- No
If yes, specify make and model:
8. In regard to ergonomic setting, if applicable:
Do you require specific seating or ergonomic devices?
- Yes
- No
If yes, specify:
If you use a wheelchair or a scooter:
What is the space required?
Is a higher table required?
- Yes
- No
If yes, at what knee clearance?
Is a device for holding paper or testing materials required?
- Yes
- No
If yes, specify:
Other:
9. In regard to transportation, if applicable:
Do you require a drop-off site?
- Yes
- No
Do you require an accessible parking spot?
- Yes
- No
Do you need assistance to travel to the assessment site?
- Yes
- No
Do you need assistance to go to the assessment room from a drop-off point?
- Yes
- No
10. Have you received any accommodations for your current functional limitations in past appointment process, at school or on the job? If so, please describe.
11. What accommodations do you feel are necessary in the current appointment process? Please describe for each assessment situation (for example: written test, interview, group task, simulation, etc).
12. Please add any other relevant information:
PLEASE NOTE: If you present limitations that affect cognitive or emotional functioning, you may be required to provide additional documentation from a professional who is qualified in the specific type of disability and who is accredited by the appropriate professional association of the province in which he or she works.
Information on Visual Functional Limitations
This information is required to determine any assessment accommodations that might be necessary in an appointment process within the Public Service of Canada.
1. Please describe your current functional limitations (for example: low vision, lack of peripheral vision or central vision, blind, blind in one eye, etc.)
2. Is the disability associated with any other medical condition or disability?
- Yes
- No
If yes specify:
3. Is the condition stable?
- Yes
- No
If no, please describe:
4. Specify the adaptive methods (technology, format or services) you normally use, if applicable, for the following: (Specify as many as apply)
Reading textual information
- Large print text material, specify the acceptable font size:
- Electronic format
- Close Circuit Television (CCTV)
- Magnifying lens
- Screen magnifier, specify which one:
- Screen reader, specify which one:
- Refreshable Braille display
- Reader (person reading text aloud)
- Braille, specify which grade:
- Other, specify:
Writing short answers or take notes
- Scribe (person who takes notes)
- Computer
- Braille note-taker
- Slate and stylus
- Perkins Brailler
- Other, specify:
Writing and editing documents
- Computer with large screen
- Computer with a screen magnifier, specify which one:
- Computer and a screen reader, specify which one:
- Computer and a refreshable Braille display
- Computer and a Braille printer
- Scribe (person who takes notes)
- Other, specify:
5. Speed of reading using preferred format:
- Normal
- Slower
Speed of writing by hand:
- Normal
- Slower
Speed of keyboarding:
- Words per minute
6. Does the method or methods of reading printed materials involve an element of fatigue?
- Yes
- No
If yes, how often are breaks required? Every:
- x minutes
- x hours
7. Do you use a guide dog?
- Yes
- No
If yes, specify any specific arrangements:
8. What accommodations do you feel would meet your needs in the current appointment process? Please describe for each assessment situation (for example: written test, interview, group task, simulation, etc.)
9. For people who are deaf and blind, will an intervenor for the deaf-blind be required for the assessment?
- Yes
- No
What is your usual mode of communication? (Specify as many as apply)
- Intervenor for the deaf and blind
- Tactile sign language
- Visual sign language
- Tactile finger spelling
- Braille
- Other, specify:
10. Please add any other relevant information:
Information on Hearing Functional Limitations
This information is required to determine any assessment accommodations that might be necessary in an appointment process within the Public Service of Canada.
1. Which of the following best describes your hearing loss?
- Person who is deaf - Person who has severe or profound hearing loss and has lost his or her hearing before developing spoken language.
- Person who is deafened - Person who has experienced a severe or profound loss of hearing after having developed speech and language skills.
- Person who is hard of hearing - Person who's hearing loss does not preclude understanding spoken language - most often with the assistance of a technical aid. The hearing loss may range from mild to severe, but, with the use of a hearing aid, a person who is hard of hearing can still communicate primarily by speech.
2. Extent of hearing loss:
- Mild
- Moderate
- Severe
Hearing loss in both or one ear:
- Both
- Left only
- Right only
3. Does your hearing limitations impact on the following areas? If yes, specify
- Oral communication:
- Reading:
- Writing:
4. Did you attend a school for the deaf?
- Yes
- No
If yes, which school:
And please explain your educational experience, including:
- how you learned English and/or American Sign Language (ASL)
- highest level of education received
5. Do you use one of the following? Please specify
- Hearing aid
- Cochlear implant
- Other, specify:
- None
6. What is your preferred means of communication for interviews, oral tests and receiving instructions? (Indicate as many as appropriate)
- American Sign Language (ASL)
- Oral interpreter
- Speech reading / Lip reading
- Spoken
- Written
- Other, specify:
7. Are you normally using adaptive technology?
- Yes
- No
If yes, specify:
8. What accommodations do you feel would meet your needs in the current appointment process? Please describe for each assessment situation (for example: written test, interview, group task, simulation, etc).
9. Please provide any other relevant information on how you communicate at work (both spoken and written communication):
Information on Functional Limitations Associated with Learning Disabilities or Attention Deficit Hyperactivity Disorder (ADHD)
This information is required to determine any assessment accommodations that might be necessary in an appointment process within the Public Service of Canada.
1. At what age, and in what circumstances was it established that you had your disability?
2. Were you given specific help or accommodations during your school or post-secondary studies? If so, please describe.
3. Describe your current functional limitations which may affect your performance in assessment situations (for example: difficulties with reading, writing, numbers, spatial orientation, oral communication, memory, following directions, maintaining attention, concentration, etc.).
4. Are you taking medication?
- Yes
- No
If yes, describe the impact of the medication on your functional limitations.
5. Have you received any accommodations for your functional limitations in past assessments, or on the job? If yes, which ones?
6. Do you make use of any adaptive technology?
- Yes
- No
If yes, specify:
7. What assessment accommodations do you feel would meet your needs in the current appointment process? Please describe for each assessment situation (for example: written test, interview, group task, simulation, etc.)
8. Please add any other relevant information:
PLEASE NOTE: You may be required to provide additional documentation from a professional who is qualified in the specific type of disability and who is accredited by the appropriate regulated professional association of the province in which he or she works.
When requested, the report should include:
- a clear description of your functional limitations; and
- an interpretative summary of test scores which describes the limitations caused by the disability.
Primary navigation (left column)
Appointment Framework
- Overview
- Appointment Policy
- Delegation
- Accountability
- Appointment Framework Knowledge Test
- Guides and Tools
- Questions and Answers
- Contacts