Student Request for a Reasonable Adjustment Form

Student Disability and Reasonable Adjustment Request Form
Reasonable adjustments are practical arrangements made for students with disability so that they can access the test on the same basis as students without disability.

How to fill out this form
1. You must complete section 1 and submit to Student Services.
2. Student Services will arrange to communicate with you to complete section 2.
1. Student to Complete
Date of request

DayMonthYear
Name
Student ID
Course
Email
example@example.com
Specify requested adjustments
The adjustment is

PermanentTemporary
Temporary duration
I understand that any medical information provided will be kept in a confidential file within the Student Services in line with the Information and Records Management Policy and Procedures.

I consent for this information to be provided Student Services for the purpose of assessing and providing the requested adjustments.
Signature

Clear
Date

DayMonthYear
Please attach supporting medical documentation

Cancelof
2. Student Services to Complete
Date of received

DayMonthYear
Name
Position
Email
example@example.com
In line with the Student Disability and Reasonable Adjustments Policy andProcedures, I have discussed with Student:

the nature and functional limitations placed on the student by their disability or condition.the duration of the disability or condition and whether it is likelyto change over time.what specific adjustments are being suggested by the student and/or associate (e.g. medical report).
In line with the StudentDisability and ReasonableAdjustments Policy andProcedures, I have:

obtained (and attached) a copy of supporting medical documentation (where required).consulted with the relevant specialist (for example Human Resources, or Quality and Compliance)
The following workplace adjustment(s) have been identified and discussed with the Student as appropriate:
I confirm that the Studentsadjustment request is:

approved (next step is to create a LAP in alignment with theStudent Disability and Reasonable Adjustment Policy and Procedures)not approved (provide details in line with the Student Disability and Reasonable Adjustment Policy and Procedures)
Signature

Clear
Date

DayMonthYear
Should be Empty:

Student Disability and Reasonable Adjustment Request Form

1. Student to Complete

2. Student Services to Complete