[D]

DSA Pre-assessment Request Form (SRAC 4)


Your details
First name*	Please enter your first name
Surname*	Please enter your surname
Full postal address (permanent)*	Please enter your address
Postcode (permanent)*	Please enter your postcode
Full postal address (term time)
Postcode term time (term time)	Please enter your postcode
Phone (home)	Please enter your contact number
Mobile (term time)	Please enter your contact number
Email*	Please enter your email address
Date of birth*	Please enter your date of birth
Name of the university or college where you are studying now, or will be studying *	Please enter the name of the University or college
Title of your course*	Please enter your course title
Current year of study* (Pre entry / 1st / 2nd / 3rd / 4th)	Please enter your current year of study
Length of course*	Please enter length of course
Mode of study* (e.g. part-time / full-time / distance)	Please enter mode of study
Name and address of funding authority
ART ID / SFE Student ref number*	Please enter mode of study
The following questions will help us make the appropriate recommendations for you at your Assessment of Need. Please complete them as fully as possible.
What is your disability, medical condition or specific learning difficulty?* (e.g. dyslexia)	Please enter details
How does your disability, medical condition or specific learning difficulties affect your learning?*	Please enter details
To enable us to put any provisions in place prior to your appointment, please inform us if you have any difficulties with mobility?* For example. Do you use a guide dog, long cane or wheelchair? Do you have problems climbing stairs?	Please enter details
Have you had a previous Assessment of Needs for DSA?* If yes, please indicate the approx date and the name of the Assessment Centre. If possible please send a copy of any previous Assessment reports to us with this form.	Please enter details
What are your previous subjects/qualifications and exam grades?
GCSEs, AS and A Levels, NVQ3, BTEC National, Access to HE, etc* Please enter qualifications
Undergraduate or other qualifications
Previous examination support (e.g. at school or college)
Have you had any previous exam arrangements made for you because of your disability?
If yes, please complete the tick boxes below	Yes No
Extra time Yes No	How much time per hour?
Separate or smaller room	Yes No
Rest breaks	Yes No
Reader	Yes No
Use of computer	Yes No
Use of special software	Yes No
Papers with adapted format, e.g. printed on coloured paper; large print; braille	Yes No
If yes, details
Any other previous exam arrangements
Your study strategies
Do you own any of the following equipment?
Desktop computer	Yes No
Laptop computer	Yes No
Printer	Yes No
Scanner	Yes No
If you own a computer, please provide further details
PC or MAC	Approximate age of the machine
Operating system, e.g. Microsoft Windows XP
Specification: memory, processor speed and hardrive
Do you use any other aids to assist you with your studies, e.g. a recording device, coloured overlays
Yes No	If yes, please specify
Do you have access to the internet at your term time address?
Yes No	If yes, what is the name of your service provider?
About your course - Please ask your course leader/tutor to help complete this section if needed
Please tick all that apply to your course and indicate the approximate frequency, e.g. hours per week
Yes No Lectures	Number of hours per week
Yes No Tutorials	Number of hours per week
Yes No Seminars	Number of hours per week
Yes No Computer labs	Number of hours per week
Yes No Science labs	Number of hours per week
Yes No Placement	Number of hours per week
Yes No Group work	Number of hours per week
Yes No Field trips	Number of hours per week
Other, e.g. year abroad
Please tick all assessment activities that apply to your course and indicate the approximate frequency, e.g. number per year
Yes No Written essays	Number per year
Yes No Written exams	Number per year
Yes No Practical exams	Number per year
Yes No Phase tests	Number per year
Yes No Placement reports	Number per year
Yes No Presentations	Number per year
Other
Please list any specific software packages that are essential for all students on your course, for example, Microsoft Word, Microsoft Excel, Microsoft Access, SPSS, AutoCad, Photoshop

Is there any other information you feel we should be aware of?

Student permissions
Observation of assessments From time to time we need to set up observations of assessments for quality assurance purposes and for training of new assessors.
Please indicate whether or not you would agree to your assessment being observed	Yes No
Assessment centres annual audit requirements As an accredited assessment centre we are audited annually by the national DSA auditing body, DSA-QAG. In order for us to show that we are meeting national standards we may require that the auditor have access to your file.
Please can you confirm whether you consent giving full access of the data to the DS-QAG auditor*	Yes No
Support services at your university or college This section is only to be completed by students who are not studying at either Sheffield Hallam University or the University of Sheffield. If you are happy for us to contact your disability advisor or support service at your university or college, please provide their contact details below
Full name:
Job title:
Full postal address	Please enter your address
Postcode	Please enter your postcode
Phone number
Email address

*The personal data provided to the DSA-QAG auditor would only be processed for the specific purposes of carrying out the audit of the centre. The data would not be retained by the auditor once the audit of the centre has been completed

Sheffield Hallam University, City Campus, Howard Street, Sheffield S1 1WB, UK

Phone +44 (0)114 225 5555 | Fax +44 (0)114 225 4449

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DSA Pre-assessment Request Form (SRAC 4)

[Sheffield Hallam University]

Sheffield Hallam University, City Campus, Howard Street, Sheffield S1 1WB, UK

Phone +44 (0)114 225 5555 | Fax +44 (0)114 225 4449