Reasonable Adjustment application and notification form

Reasonable Adjustments Application Form
Reasonable Adjustments ensure that a learner’s disability, learning difficulty or access requirements are taken into account when planning assessment. This ensures learner's who can evidence their additional needs have access to fair assessment.

This document must be used for all reasonable adjustments. Applications must be submitted at least of 5 working days before the date of the first assessment. Adjustments for extra time on XAMS cannot be made available until the learner has been registered on QMIS.

Special Consideration applications - Please contact FutureQuals.

Please refer to the current Reasonable Adjustment and Special Considerations Policy, which can be found on the FutureQuals website. www.futurequals.com/policiesand procedures

FutureQuals requires centres to keep a log of all reasonable adjustments, including those that have been declined.
Application and notification details
Please complete a separate form for each learner and help us to ensure your learners recieve adjustments they are entitled to, by submitting with the appropriate supporting evidence at least 5 working days before the assessment date.
Centre Number*
Centre Name*
Learner Number (if the learner has not been registered yet, please enter TBC (to be confirmed) and contact us via email to confirm the learner number as soon as they have been registered).*
Learner Name*
Qualification title/level*
Does the reasonable adjustment apply to all units*
If no, unit numbers to which the reasonable adjustment is to apply
Proposed assessment date*

DayMonthYear
Proposed assessment method(s)*

Written questionsOral questionsObservationProfessional discussionWitness testimonyLearner statementAssignmentProjectCase studyMCQSkills testIf other, please add details here
Details of the application - please describe how the additional need(s) were identified and the supporting evidence. This must include recommendations regarding specific adjustments that will support the learner. You can also include details of the learners "normal ways of working".*
Reason for the application - Additional need(s)*

DyslexiaDyspraxiaDyscalculiaADD/ADHDAutismAspergers sydromeHearing impairmentVisual impairmentIf other or disability as defined by the Equality Act 2010, please provide additional information
Centre's must ensure that suitably qualified personnel check that the evidence is current and relevant to the learner. Examples of evidence could be but are not limited to:

- a Statement of Special Educational Needs relating to secondary education, or an Education, Health and Care Plan, which confirms the Learner’s disability
- a letter from a hospital consultant/Occupational Health Service etc.
- an assessment carried out no earlier than the start of Year 9 by a specialist assessor confirming a learning difficulty relating to secondary/further education, including standardised test scores.

In the absence of formal evidence, FutureQuals will consider a history of need within the Centre. This should include information about the support received by the learner during the learning programme and during formative assessments. Evidence of the way in which the learner's needs are being met during the learning programme should be documented for audit purposes.
Please provide the page number(s) where the evidence of the reasonable adjustment applied for can be found:*
Evidence to support the application*

Cancelof
Reasonable adjustment(s) requested. Please only select those for which you have supporting evidence*

Extra time up to 25%Extra time in excess of 25% (provide further information in details of the application)ReaderScribeColoured overlaySeparate roomIf other, please provide details of reasonable adjustment(s) requested
Please provide details of access facilitator(s), for example reader and/or scribe (in addition to an invigilator where the application relates to a controlled assessment)
Person making application and declaration
I confirm that:*

The appropriate evidence has been attached to support the applicationThe information provided is accurate;The centre will be able to provide the arrangements requested;The reasonable adjustments will be implemented in accordance with FutureQuals’ guidance
Name*
Last Name*
Email confirmation will be sent to this address*
example@example.com
Notification also to be sent to
example@example.com
Contact phone Number - for any queries*

Area CodePhone Number
Position in centre*
Date submitted*

DayMonthYear
Centres should note that a negative decision can be appealed

(please see FutureQuals’ Appeals Policy)
Should be Empty:

Reasonable Adjustments Application Form

Application and notification details

Person making application and declaration