Competent Authority Form

Patron Information:

Name:________________________________________________

Library Card Number:_____________________________________

I consent to the library collecting personal information for the purpose of granting me access to alternative format library materials as a person with a perceptual disability.

Applicant’s Signature: ____________________________________

Certification by a Competent Authority*:

I certify that the applicant as a perceptual disability as defined in the Canadian Copyright Act and is unable to use standard print material because of one of the following:

• Severe or total impairment of sight or the inability to focus or move one’s eyes
• The inability to hold or manipulate a book
• An impairment relating to comprehension

Name of competent authority: _____________________________
Signature:_____________________________________________
Occupation: ___________________________________________
Address:_______________________________________________
Telephone:____________________________________________
Library Staff Member:____________________________________

*A competent authority must have the knowledge, skill and judgment to determine if someone has a perceptual disability. A Doctor of Medicine, Ophthalmologist, Optometrist, Registered Nurse, Registered Occupational Therapist, Registered Physical Therapist, Registered Social Worker and a Special Education Teacher with a Special Education Certificate can each act within their own capacity and within their scope of their practice as a competent authority.

Collection Notice

The Canadian Copyright Act permits the production and sharing of accessible formats of original material if there is no existing accessible format available and only for persons with a perceptual disability. In accordance with subsection 36(1)(a) and (b) of the Freedom of Information and Protection of Privacy Act, the personal information collected on this form is used by the library for the purpose of satisfying the eligibility requirements for providing library patrons with access to the National Network for Equitable Library Service (NNELS) which contains the accessible format material. Your library card number will be shared with NNELS in order to facilitate direct access to their online library collection.

If you have any questions regarding the collection, use or disclosure of your personal information, please contact your local public library.