Course/Funding information

  • DOB

  • E-mail

  • Address

  • Telephone

  • Mobile

  • Emargency Contract (Name, Number)

  • Course Name

  • School Code

  • Start Date

  • End Date

  • Outcomes (what does the student want to do after this course e.g. Apprenticeship, employment, University?)

  • Employment/ voluntary work/ work placement

  • Education Background (Type of school, any exams taken)

Visual Impairement

  • Are you registered blind?

  • Date of registration

  • Date of last visit and review to eye consultant?

  • Consultant name and hospital

  • Medical conditions/ Eye condition

  • Describe your Peripheral / Central vision and Visual Acuity scores

  • VI medical information to be requested from (Name, address, phone number)

  • Date of VI information received

Support Requirements

  • Support Requirements

Support History


  • Adjustments

Exam Access Arrangements

  • EAA

  • extra time-%

  • software

  • Coloured paper

  • What worked well/what might have helped you that you didn't have?

Other relevant information e.g. Software use, font & colour etc

  • Handout paper colour(s)

  • Overlay colour(s)

  • MP3 (speed)

Format for notes/ handouts

  • Fonts and sizes

  • Text colour

  • Background colour

  • Braille


  • Enlarged keys

  • Letter colour keyboard colour

  • Braille keyboard


  • Dragon, Jaws, Supernova,

Computer setting

  • Task bar, enlarged icons, cursor etc

Technical Aids

  • Magnifier -handheld - electronic (Looky+)

  • Reading pens

  • Dictaphone

  • Echo Smartpen / Smartpen 3

  • Perkins brailler

Handwriting sample

Can you read your handwriting-If yes please can you show us what size you write on using the separate piece of paper.

  • Sample of students writing

Further Information


  • Staff signature

  • Student signature

  • Date

Office Use Only

  • Person to cost for:

  • Date:

  • Time Taken:

  • Person to cost for:

  • Date:

  • Time taken:

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