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
2 digit day, 2 digit month, 4 digit year
Name
Student ID
Course
Email
example@example.com
Specify requested adjustments
The adjustment is
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
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Please attach supporting medical documentation

Cancelof
2. Student Services to Complete
Date of received

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Name
Position
Email
example@example.com
In line with the Student Disability and Reasonable Adjustments Policy andProcedures, I have discussed with Student:
In line with the StudentDisability and ReasonableAdjustments Policy andProcedures, I have:
The following workplace adjustment(s) have been identified and discussed with the Student as appropriate:
I confirm that the Studentsadjustment request is:
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Should be Empty:

Student Disability and Reasonable Adjustment Request Form

1. Student to Complete

2. Student Services to Complete