Page 1 of 2 QALIPU ENROLMENT REQUEST DISABILITY DECLARATION - INSTRUCTIONS These guidelines are for the applicant and the medical provider to read in relation to the completion of the Declaration of the disability ► which must be completed and submitted in order for a reassessment to occur. Definitions (for the purpose of this reassessment process) Field Definition (a) Disability A long term physical, mental, intellectual, or sensory impairments which, through interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others. (b) Substantial portion not necessarily the entirety of the specified period but most of it. 1. Applicant information The applicant or the guardian of the applicant is to complete this section. Ensure that all necessary information is filled in. 2. Medical provider To be completed by the medical provider that you saw at the time to diagnose or facilitate the recovery or treatment information of your disability between 2006 and September 22, 2011. If your medical provider at that time is unavailable (e.g. deceased, no longer a licensed medical provider) bring this form and your medical records of your disability between 2006 and September 22, 2011 to a medical provider. If the medical provider is licensed/practices outside of Canada, we require additional documentation in the form of a certified copy of the medical provider's license. A list of the types of medical providers who are permitted to complete the form is available below. 3. Declaration To be completed by the medical provider and the applicant to confirm which scenario is applicable - it is possible that an applicant falls within one than one scenario. There are three scenarios: Scenario A applies to applicants who were restricted or prohibited from travel due to their disability. Scenario B applies to applicants who were required to move from in or around one of the geographic locations of the Mi'kmaq Group of Indians to accommodate their disability. Scenario C applies to applicants who were required to move from elsewhere on the island of Newfoundland to accommodate their disability. The applicant must provide the evidence requested. For scenario A, B and C, the medical provider must provide a brief description of the circumstances of the disability. 4. Signature To be completed by the medical provider and the applicant to confirm that all of the information that has been provided is true. Recognized Medical Providers ► This list represents which professions are considered to be medical providers across Canada. Lists were collected from the Royal College of Physicians and Surgeons of Canada and from all provinces to consolidate them into this list. The criteria to be considered a medical provider is that the individual must be a Doctor of Medicine (M.D.) and specialize in a field of medicine recognized by a professional medical association responsible for the regulation of the practice of medicine in the jurisdiction where the individual holds a valid, current license. Note: Certain professions are excluded from the definition of a medical provider as they are not a Doctor of Medicine (M.D.). This includes psychologist, dentist, chiropractor, physiotherapist and naturopath. Adolescent medicine specialist Allergist (immunologist) Anesthesiologist Cardiac electrophysiologist Cardiologist Cardiovascular surgeon Colorectal surgeon Critical care medicine specialist Dermatologist Developmental pediatrician Emergency medicine specialist Endocrinologist Family doctor Gastroenterologist General Practitioner Geriatric medicine specialist Gynecologic oncologist Gynecologist Hand surgeon Hematologist Hepatologist Hospice and palliative medicine Hospitalist Hyperbaric physician specialist Infectious disease specialist Internist Interventional cardiologist Medical geneticist Neonatologist Nephrologist Neurological surgeon Neurologist Neuropsychiatrist Nuclear medicine specialist Obstetrician Occupational medicine specialist Oncologist Ophthalmologist Oral surgeon (maxillofacial surgeon) Orthopedic surgeon Osteopathic physician (DO) Otolaryngologist Pain management specialist Pediatrician (ear, nose, and throat specialist) Perinatologist Physiatrist Plastic surgeon Proctologist Psychiatrist Radiation oncologist Radiologist Reproductive endocrinologist Respirologist Rheumatologist Spinal cord injury specialist Sports medicine specialist Surgeon Thoracic surgeon Urologist INTER 83-181IE 2021-07-29 Page 2 of 2 Documents to be provided ► Applicants need to provide either of the following to prove that they had resided in or around one of the communities of the Mi’kmaq Group of Indians of Newfoundland or elsewhere on the island of Newfoundland; • One (1) document listed in collumn Type 1, OR • Two (2) documents such as those listed in the column Type 2 Type 1 (provide one of these) Type 2 (provide two of these) • Notice of Assessment for income tax purposes; • Any provincial permit/license showing your address current with • Notice of Assessment for municipal tax purposes; September 22, 2011; and • • Real property lease or rental agreement; Utility bills dated to include September 20, 2011 such as; • • Affidavit from a Municipal Official or Chief. Property Tax / Water • Cable / Telephone • Electrical / Hydro / Oil Note: A document of this type, dated in 2021 will be accepted as Note: Any other document confirming residency current with evidence of your address in the previous year September 22, 2011 Communities of Mi’kmaq Group of Indians of Newfoundland (listed in the Agreement for the recognition of the Qalipu Mi’kmaq Band) Abraham's Cove Appleton Badger Birchy Bay Bishop's Falls Black Duck Brook Black Duck Siding Boswarlos Botwood Brown's Arm Buchans Burgeo Campbells Creek Campbellton Cape St. George Comfort Cove Corner Brook Cox's Cove Deer Lake Flat Bay Fox Island River Gallants Gander Gander Bay North Gander Bay South Gilliams Glenwood Grand Falls /Windsor Hughes Brook Humber Arm South Irishtown/Summerside Kippens Lark Harbour Leading Tickles Lewisporte Lourdes Lower Cove Mainland Massey Drive Mattis Point McIvers Meadows Millertown Mount Moriah Norris Arm Northern Arm Pasadena Peterview Piccadilly Point Leamington Port au Port East Port au Port West Red Island Sheaves Cove Ship Cove Sop's Arm St. Albans St. Fintan's St. George's St. Teresa's Steady Brook Stephenville Stephenville Crossing Swift Current Three Rock Cove West Bay York Harbour Geographic locations around communities of Mi'kmaq group of Indians of Newfoundland Barachois Brook Bay of Islands Baytona Beaver Cove Bellmans Cove Benton Berry Head Bonne Bay Pond Bottle Cove Boyd's Cove Bridgeport Brighton Buchans Junction Camp Boogy Carmanville Cartyville Chanceport Clarkes Head Codroy Pond Cold Brook Cormack Cottlesville Cottrell's Cove Curling Davidsville De Grau Dormans Cove Embree Fairbanks - Hillgrade Fischells Fortune Harbour Frederickton Frenchman's Cove Gambo Garden Cove George's Point Glover Harbour Goose Cove Grand Jardin Harris Point Heatherton Highlands Horwood Howley Humber Village Jackson's Arm Jeffrey's Jerry's Nose Laurenceton Little Burnt Bay Little Harbour Little Rapids Lock Leven Long point Loon Bay Luches Bight/Beaumont Maidstone Main Point Marches Point Masons Cove McKay's Michael's Harbour Milltown/Head of Bay Moreton's Harbour Morrisville Nicholsville d'Espoir Noels Pond Noggin Cove Norris Arm North Side North Branch North Harbour Notre Dame Junction Petit Jardin Petries Phillips Head Pilley's Cove/Island Pleasantview Point au Mal Point of Bay Pollard Point Port Albert Porterville Purbeck's Cove Pynn's Brook Ramea RedBrook Reidville River Brook Robinsons Rodgers Cove Romaines Salmon Cove Seal Cove Seal Rocks Shallops Cove Spruce Brook St Veronica's St. David's St. Joseph's Cove Stanhope St-Judes Stoneville Summerford Swanger Cove Triton Victoria Cove Virgin Arm/Carter's Westport Wings Point Winterhouse Woody Island INTER 83-181IE 2021-07-29.