Referral Form

Surname: *

First names (in full): *

Please give the name of your funding body (Local Education (LA), National Health Student Grants (NHS), or other Sponsoring Agency

Please give your Customer Reference Number (You will find this on the letter you received from the Funding Body (SFE, NHS or Sponsoring Agency)

Please give the name of the university or college where you are / will be studying

Is your course:

Have you ever had a DSA Assessment before?

Referred by:

Information on Your Disability and How it Affects Your Learning
Any information given will be treated as strictly confidential, and will only be used to ensure you have as full an assessment of your needs as possible

What is your disability, medical condition, or mental health problem?

How does your disability or condition affect your ability to study? Please give details

If You Are Deaf, Do You Use:

Personal Assistive Technology Used

Do You Use Any Other Aids or Technology to Assist Your Study? e.g. a computer, keyguard, magnifying aids?

Do You Use Any Software? e.g. Microsoft Office / Word, screen enlarging software, voice recognition software, etc?

If yes, please give details:

Previous Examination Requirements

Have You Previously Been Awarded Extra Time for Examinations?

If yes, how much extra time per hour was awarded?

Were you given:

Did You Have a Reader to Ensure You Understood the Questions Correctly?

How Did You Produce Your Written Work in Examinations?

Please give details of any other examination arrangements you have received:

Previous Education

It would be helpful for you (not compulsory) to provide full details of the courses you studied at college or 6th Form, including when and where you studied them, and the grades you achieved.

Other Further Education or Higher Education Courses

It would helpful for you (not compulsory) to provide full details of other courses you studied at college or university previously, including when and where you studied them, and which grades you achieved.

Please Provide Brief Employment Details

It would helpful for you (not compulsory) to provide brief details of your employment history.

About Your Higher Education Course

It will be very helpful if you can tell us how your course is delivered. Please tick any of the following that apply:

Are you expected to undertake:

Placements

Study Visits / Field Trips

Residential Visits

How is your course assessed? Please tick any of the following that apply:

Other, please specify:

N.B. If you have difficulty completing this section we can contact your course tutor. Please ensure that you have given their details at the start of this document.

Course Hardware and Software

N.B. If you are unsure of the answers to these questions, please give contact details of your course technician or someone whom we could contact.

Please give details of the computer hardware or software used on your course

Which software do you use for the following:

Other course software used, please state:

Contact details of your course technician (IT Helpdesk for your course):

Support Services at Your University or College

Please provide the contact details of the Disability Support Service at your University or College:

Address:

I agree that Broadbent & Co, and the disability advisor at my university or college may exchange information about my application for DSA, where this is necessary to make sure I get the help I need.

Once you have completed this form, and are sure the information provided is correct, please click the 'submit' button below to send your details to our team. Someone will be in contact shortly.