Disability Support Services Form | University Campus Oldham

Section A – Personal and Course Information

Name

First

Surname

Phone

Date of Birth

Email

Name of course

Section B – Disability Information

Please tick the appropriate box:

Specific learning difficulty (e.g. dyslexia)

Asperger syndrome, autistic disorder or social communication difficulties

Visual/hearing impairment

Long standing illness or health condition (e.g. diabetes, epilepsy)

Mental health issues including self-harm and suicidal thoughts/actions

Past/current drug use

Other disability – Please state: Other disability – Please state:

Not known

Please provide the name of your disability below:

We require a copy of any evidence you have of your disability, mental health condition, specific learning difficulty or medical condition (e.g. Educational Psychologist’s Report, Statement of Educational Needs, Needs Assessment, Medical Report.) This will help us to speed up the process of ensuring you receive the support – thank you.

I enclose a piece of evidence:

Evidence is to follow:

Section C – Reasonable Adjustments

If you require reasonable adjustments to be implemented while studying at University Campus Oldham, then you will need to book an appointment with the Disability/Mental Health and Wellbeing Officers to further discuss your support needs and enable a Learning Support Plan to be created. This will ensure that the relevant members of staff are aware of your needs and reasonable adjustments may be made whilst you study at University Campus Oldham.

Please be aware that if you require a Personal Emergency Evacuation Plan (PEEP), a Learning Support Plan or want to apply for exam concessions due to your disability then you must arrange an appointment with the Disability Officer.

Yes – I require a meeting

No – I do not require a meeting

Section D – Release of information

Please complete this section of the form to indicate your consent for the Disability Service to hold information about you and your disability and to disseminate this information to relevant individuals and organisations. The purpose behind this is ensure the necessary support and adjustments are in place during your studies.

The type of information we hold includes (but is not limited to):

Registration Form
Evidence of your disability
Disabled Students’ Allowance correspondence
Other correspondence such as letters, emails, etc.
Sessional notes from 6 week monitoring and/or counselling sessions

Examples of individuals and/or organisations to whom we may disclose disability information:

Staff in your academic

department and in Library Services

DSA Assessment Centres
Your funding body
Other appropriate external agencies.

Do you give consent?

I consent to information being held and disclosed.

I do not consent to information being held and disclosed.

UCO operates a confidentiality policy and information will be passed on appropriately and only with your consent. There may be rare circumstances where information about your disability is disclosed without your consent, for example if there is concern that you are at risk. This will only be done in circumstances permitted by the Data Protection Act 2018.

If you do not consent to information about your disability being held and shared, the University may not be able to fully support your requirements.

Section E – Funding Information

Disabled Student’s Allowance (DSA) – UK students only

The DSA helps to pay for extra costs you may have as a direct result of your disability. The allowance can help with the cost of an academic support worker, items of specialist equipment, travel and other course related costs.

Further information and the application form can be obtained on the website at:

https://www.gov.uk/disabled-students-allowances-dsas/overview

Have you applied for the Disabled Students’ Allowance?

Yes

No

Support is available for students not from England, overseas students and those not applying for or not eligible for DSA. Please contact us to discuss this further.

Section F – Declaration

Your Name

Date

Signed

Digital Siganture

Section G – Further Information

If you would like any further information, please contact the UCO’s Disability Officer:

Laura Macmillan
University Campus Oldham
University Way
Oldham
OL1 1BB

Tel: 0161 344 8877
Email: laura.macmillan@oldham.ac.uk

This form is also available in alternative formats. Please contact us and let us know your preferred format.