Pre-Assessment Details
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.
Please complete this form and return by email it to or post or deliver in in person to the address below before your appointment:
De Montfort University Centre for Accessibility Needs,
Ground Floor,
Gateway House,
The Gateway,
Leicester,
Leicestershire,
LE1 9BH
A: Personal details
Full name:Date of Birth:
Home Address: / Term-time Address (if known):
Telephone number:
Mobile number:
Email address:
B: Course details
Title of Course:Name and location of University or College:
Full Time or Part Time:
Undergraduate or Postgraduate:
Course Start Date:
Course End Date:
Current Year of Study:
Funding body:
e.g. Student Finance England, Student Finance Wales, Student Finance Northern Ireland, Student Awards Agency Scotland, Research Council UK, NHS Student Bursaries, NHS Social Work Bursaries
Customer Reference Number (CRN) or NHS Bursary Number:
Disability Team named contact. Please provide further contact details (telephone number and email) if you know them:
Course Leader named contact. Please provide further contact details (telephone number and email) if you know them:
How is your course taught? Please indicate Yes or No by circling your answer or deleting as appropriate:
Seminars / Yes / No
Lectures / Yes / No
Tutorials / Yes / No
Sciences Lab / Yes / No
Computer Labs / Yes / No
Placements / Yes / No
Portfolio / Yes / No
Exhibitions / Yes / No
Groupwork / Yes / No
Field trips / Yes / No
Distance Learning / Yes / No
Practical activities, such as performance,
creative output, sports, clinical work, mooting / Yes / No
Other (please specify) / Yes / No
Section C: Disability and previous support details
What type of disability are you being assessed for (you will find this in your funding body approval 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)?
Have you previously been assessed for DSA funding?
If so, please give the date and details.
Please attach a copy of the report, if available. / Yes / No
Further details:
Section D: Equipment details
If you own a computer, please provide the following details. If you do not know how to do this, please see the guide included at the end of this form.
You might find it easiest to take a screen shot of the information by pressing the Prt Scr (or print screen) key on your keyboard near the F12 key (top right) – or briefly holding the power button on a tablet /Type of equipment (for example laptop, desktop, tablet) – or write / type NONE
Brand name and model no if known
Operating system (for example, Windows 7 or Apple Yosemite)
Hard drive storage capacity (usually GB):
Processor speed (usually Ghz)
and type (it should have a name and number e.g. TM5200)
RAM (usually GB):
How old is the computer?
Is it still under warranty? / Yes / No
Is it insured? / Yes / No
Is there any other equipment e.g. hardware or software that you use to help you with your studies?
E. Special requirements
Do you require any special assistance or facilities in order to attend your appointment?If yes, please provide details: / Yes / No
Do you require a booked parking space? You do not have to be a blue badge holder. / Yes / No
F. Permissions
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.Please confirm if you are happy to give your permission? /
Yes / No
Occasionally, we need to observe assessments for quality monitoring and staff training purposes. Please indicate whether or not you are happy for your assessment to be observed: / Yes / No
If you would like to give permission to share information with another person (for example parent, guardian, spouse, or other trusted person) please confirm their name and contact details: / Name:
Relationship to you:
Contact details:
Date:
Student Signature:
(type name if sent by email)
How to find your computer details
Details of the Operating System, Processor speed and RAM:
For Windows 7
Click on Start
Right-click on Computer
In the list of options displayed, click Properties
For Windows 8
Hover over the top right hand corner of the screen so that the Charms appear.
Click Settings
Click PC Info.
For Windows 10
Right click the windows icon in the bottom left of the screen
Click system form the list
OR
Click start and type “system info” in the search box. This will also tell you the size of the hard drive
For Mac
Click the Apple icon at the left of the top toolbar
Click About this Mac
Click More info
Details of the Hard Drive size
For Windows 7
Click Start
Click Computer
You should be able to see your hard drive(s) and their size detailed.
For Windows 8
Type “This PC” into the search box on the start screen, and then click This PC from the search results
You should be able to see your hard drive(s) and their size detailed.
For Mac
Click the Apple icon at the left of the top toolbar
Click About this Mac
Click More info
Click Storage
Pre-Assessment Questionnaire please return to Gateway House, The Gateway, Leicester LE1 9BH [November 2016] Page 6 of 6