Pre-Assessment form
Please return this form to: or Fax to: 02920 874947; Post: Assessment Centre Cardiff, Student Support Centre, Cardiff University, 50 Park Place, Cathays, Cardiff, CF10 3AT.
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 require the following information in advance. This will enable us to do any prior research needed, so that we can consider the full range of support available.
STUDENT DETAILS Name:(CRN: ) / Date of Birth:
Home Address: / Term Address (if known):
Enter address if incorrect. / Enter address if incorrect. /
Mobile / Enter mobile if incorrect. /
Tel / Enter telephone if incorrect. /
Email / Enter email if incorrect. /
COURSE NAME (* delete as appropriate)
Full/Part Time* / Year of Study Click here to enter text.
Post/Under Graduate* / Course Ends
INSTITUTION DETAILS
Disability Team
Named Contact (if known)
Click here to enter text.
Tel:
Click here to enter text.
Email:
Click here to enter text. / Course Leader
Named Contact: (if known)
Tel: Click here to enter text.
Email: Click here to enter text.
We will not disclose 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.
Please confirm if you are happy to give your permission? / ☐ Yes ☐ No
- What type of disability are you being assessed for (you will find this in your funding body letter)?
- What are the main difficulties caused by your disability?
- What type of support have you received in the past (e.g. in school/college)?
- What type of equipment do you have access to (e.g. computer, tablet, smartphone). Please provide details of the make and model of each.
Please complete ONLY If you currently have personal access to a computer:
Laptop ☐ Desktop ☐ PC ☐ Apple Mac ☐
Operating System e.g. Windows 7, Vista: Click here to enter text.
Please give your computers specifications, to find this information go to ‘My Computer’, click on ‘View System Information’:
Processor: Click here to enter text. Memory: Click here to enter text.
- If you have been previously assessed for DSA funding, please give the date and details.
6. The following information helps us make your assessment interview accessible
If you have mobility difficulties please give details
☐ Wheelchair user
☐ Problems climbing stairs / ☐Guide dog user
☐White cane user
If you have a hearing impairment what is your preferred method of communication?
Click here to enter text.
Do you require a translator to be present at the assessment?
Click here to enter text.
Please provide details of any other access needs which we need to meet?
Click here to enter text.
Student Name: / Date:
Signature:
For Office Use only.
Part 2 – Draft Report Agreement
Funding Body:
Tel:
Email:
Course Requirements
Lectures/ Tutorials/ Seminars.Practical and other campus activities.
Off campus activities
Assessment methods
Equipment/Support discussed and recommended.
Part 1 – Equipment Demonstration/Recommendations
Equipment, technology and support / Demonstrated/ Trialled / RecommendedStudent’s Name:Signature:
Assessor’s Name: Signature:
Date of interview:Location:
Student’s name:
1.After your assessment has been completed, your assessor will write a report outlining the recommendations he or she has made based on what is discussed during your assessment. A copy of your report will be sent to you and to your funding body.
I wish to see a draft copy of the needs assessment report before it is sent to my funding body.
I do not wish to see a draft copy of the needs assessment report before it is sent to my funding body.
Please note If you do want to see a draft copy of your report you have three working days to authorise it. In the event we do not hear from you within the three days we will send your report to your funding body. Also you should be aware that requesting a draft copy of your report will add approximately 3 working days to the waiting time before you receive your recommendations.
Part 3 – Consent to Information Dissemination
2.It would be beneficial for you if your University receives a copy of the report so that they can help to put in place any strategies to assist you with your course. We need your consent in order for us to send a copy of your report to, and/or discuss your case by name with, anyone other than yourself and your funding body.
*Delete as appropriate
I agree/do not agree to the assessor discussing my disability needs, in relation to recommended support, with my University or College
I agree/do not agree to the Assessment Centre Cardiff sending a copy of my needs assessment report to the Disability Advisor of my University or College
3.The Assessment Centre Cardiff is audited by an external body, DSA-QAG. These audits ensure this Centre is complying with the relevant legislation and guidance which assures the quality of assessments. As part of the audit your needs assessment report may be randomly selected to be scrutinised by the auditor. As the needs assessment report includes personal data and personal sensitive data as defined under the Data Protection Act 1998 we require your consent before we can provide the Auditor with a copy of your report. The data would not be retained by the Auditor once the audit had been completed.
*Delete as appropriate
I agree/do not agree that my personal and personal sensitive data can be transferred from the Assessment Centre Cardiff to the DSA-QAG Auditor and to the processing of this data by the auditor.
4. In furthering your DSA application, suppliers of equipment and services will be contacted in order to provide quotations for equipment and services agreed. In requesting quotations your name and contact details will be passed to the supplier.
I understand that in order to further my DSA application my contact details and name will be forwarded to service providers.
Student’s Signature: ______Date: ____/____/_____