Pre-Assessment Form

PLEASE READ AND COMPLETE ALL SECTIONS

The purpose of the DSA study Needs Assessment is to determine what difficulties you may face with your study due to your disability and to consider what support can be provided to overcome those difficulties. In order to get the best outcome from this assessment, we must have some information in advance. This will enable us to do any prior research needed, so that we can consider the full range of support available. You must submit the following to AccessCentral before your appointment:
  • This form completed in full.
  • A copy of your Medical Evidence – the information you sent to your funding body eg a doctor's letter, a dyslexia diagnostic report or other document.
  • A copy of the letter you have received from your funding body asking you to arrange a Study Needs Assessment,
Please complete ALL sections or write NONE.
Customer Reference Number (SFE / SFW / SAAS) or NHS Bursary Number:
Funding Body:
Title:
First Name: *
Last Name: *
Date of Birth: *
(dd/mm/yy)
HOME ADDRESS
Home Address 1:
Home Address 2:
Home Address 3:
Home Address 4:
Home Address 5:
Home Postcode:
Mobile Number: *
Alternative Phone Number:
Email Address (College or University one preferred):
TERM ADDRESS (if known)
Term Address 1:
Term Address 2:
Term Address 3:
Term Address 4:
Term Address 5:
Term Postcode:
COURSE DETAILS
Full course name:
Full or Part Time:
Year of Study:
Under / Postgraduate:
Course Ends (mm/yy):
University / College:
Disability Officer:
Phone:
Email:
Course Leader:
Other course contact:
Phone:
Course Leader email:
PREVIOUS QUALIFICATIONS
Number of GCSEs at grade C or higher:
Number of AS level passes at any grade:
Number of A level passes at any grade:
Other academic qualifications:
Disabilties or medical conditions that have been accepted by your funding body (as shown on the letter from your funding body):
What are the main disability related difficulties that you experience when studying?
1. Details of any support you have received previously (eg extra time, learning support assistant):
2. What type of support has been most helpful to you in your studies previously?
3. Detail and list below equipment you already own that you can use for your studies. DO NOT list any equipment shared with your family or another person. Give full details of model, specification and date of purchase any extended warranty cover in place. If you do not have any equipment state NONE:
Please bring any mobile/tablet equipment you use to your assessment.
4. Do you currently use any other assistive technology or software?
If yes, please provide details below:
5. If you have been previously assessed for DSA support, please give the date and details of what was provided. Please attach a copy of the report, if available:
6. Please provide any other information that you feel is relevant:
Please upload your medical evidence:
Please upload the letter from your funding body:


NB If you do not have your medical evidence because it was not returned by your funding body please contact us immediately. You can request that SFE return your evidence by emailing dsa_team@slc.co.uk and quoting your customer reference number.
Please note that we can only make recommendations for conditions that your funding body have accepted medical evidence for.


Now, please read and sign the declarations below.

We will not disclose your identity to your University / College without your permission. However, it may be helpful for us to contact your Disability Officer / Course Leader for information regarding your course and the support already available. Do you give your permission for us to contact staff at your University should the need arise?

We may wish to observe the assessor undertaking your assessment. This is to help us to monitor the services we provide and to help us to ensure that our staff are appropriately trained and offering the high quality service we wish to provide for you, our customer. If appropriate, do you agree for your assessment to be observed?

AccessCentral would like to ask you about our performance and how the recommended support is working for you. Would you be happy for us to include you in these questionnaires? *


I confirm that the information provided above is correct and I understand that it is my responsibility to provide all relevant information to AccessCentral before and during the assessment.

Student Name:
Date: *
(dd/mm/yy)
Signature: *
(please use your cursor to draw your signature)