Download Medical Form for Disabled Students: Applying for Accommodations at Royal Holloway and more Schemes and Mind Maps Medicine in PDF only on Docsity!
Medical Evidence
About this form
To apply for Disabled Student’s Allowance (DSA) and to receive support from Royal Holloway during
your studies, a medical professional (for example, your GP) needs to provide information about your
disability (ies) on this form. If you already have evidence of your disability, then you will only need
this form to be completed if you have disability related accommodation requirements or exam access
arrangements (if not covered by our standard arrangements, see page 5)
You don’t need to complete this form if you have a specific learning difficulty.
What you need to do
You need to complete your details in section 1.
Then pass the form to the medical professional to complete, sign and date the declaration. Please
note that you may be required to make an appointment in order for this form to be completed.
Once they have completed the form, make sure you return it to the addresses on page 6.
You should keep a copy of this form for your own records. You may require it later.
SECTION 1 : YOUR PERSONAL DETAILS
1.1 SFE Customer Reference Number: (if known)
1.2 RHUL Student ID Number: (if known)
1.3 First Name:
1.4 Surname:
1.5 Date of Birth:
1.6 I give my consent for my GP to complete the following sections of this form: Section 2 Section 3 Section 4 Section 5 Section 6
Signature Date
Now pass this form to the medical professional.
SECTION 2 : MEDICAL PROFESSIONAL DETAILS
Sections 2, 3, 4 , 5 & 6 should be completed by a medical professional
To enable this student to access support at university we need you to give us information about the nature of the student’s disability. Please complete the rest of the form, read, sign and date the declaration, then pass the form back to the student. As the student cannot reclaim any charge made for completing this form we ask that it is provided free of charge.
2. 1 Your details:
2.2 Practice or organisation details:
2.3 What is your professional involvement with the student? (You only need to give details if this isn’t apparent from your job title)
Full Name:
Job Title:
Certificate or registration number (GMC, HPC, NMC):
Type of practice or organisation: GP Practice Primary Care Team
Secondary Care Team Hospital Other (please give details)
Name of practice or organisation:
Address:
Postcode:
Contact number:
Where possible use your practice or organisation’s stamp.
Stamp here
SECTION 4: DISABILITY RELATED ACCOMMODATION REQUIREMENTS
4.3 Please indicate which of the following adjustments would be required:
A mobility-adapted room (if using mobility aids) Accommodation for a carer (provided by Social Services) Emergency pull cords in bedroom & bathroom (only available to students who have a fulltime carer provided by Social Services) Accommodation with sufficient space and the structural integrity to take a hoist Mechanically opening doors A room on the ground floor A room on campus (main campus, both sides of A30) Room with ensuite facilities A room in catered halls A room in a self-catered hall Fridge for medication (to be supplied by student) Double bed A room for the hearing impaired (flashing alarm and vibrating pillow) UK Registered Assistance Animal (e.g. Guide Dog)
Please explain the reason for any selections in the above section.
4.1 Does this student have any specific accommodation requirements?
- 2 Is this student suited to living independently in unsupervised high density student accommodation?
Yes No
Yes
The University will endeavour to put exam access arrangements in place however this may be
affected by the time of application. Please note the deadline for the receipt of requests is published
on the student intranet under Exam Access Arrangements. This is usually the end of January. After
this deadline we cannot guarantee any arrangements can be made for the current academic year.
Medical Condition Guideline Allowance Social communication impairment 15 mins per hour extra time
Serious visual impairment Dependent on severity and requires specific advice from a medical professional Serious hearing impairment Dependent on severity and requires specific advice from a medical professional Long standing illness or health condition
Dependent on severity - requires specific advice from a medical professional Mental health condition 10 mins per hour extra time
Specific learning difficulty 15 mins per hour extra time
Physical or mobility impairment Dependent on severity - requires specific advice from a medical professional
Exam Access Arrangements should only compensate for the candidate's disability and not relatively disadvantage other candidates. In order to ensure that comparable consideration may be given to each request for Exam Access Arrangements, the University reserves the right to consult its own medical officer for additional or different arrangements requested. The University has standard extra time arrangements in place which are detailed in the table below.
SECTION 5: REQUEST FOR EXAMINATION ACCESS ARRANGEMENTS (EAAs)
Students with additional time will usually be seated in smaller EAA specific venues and not main examination venues. The recommendations for extra time are inclusive of rest peri0ds.
5.1 In my professional opinion this student is likely to require the following additional arrangements which are not covered by the University’s standard adjustments:
5.2 Please briefly explain the reason for the additional arrangements:
