Information

  • Year

  • Personnel

  • Students name

  • Person Code

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

  • 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

Keyboard

  • Enlarged keys

  • Letter colour keyboard colour

  • Braille keyboard

Software

  • 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

Signatures

  • Staff signature

  • Student signature

  • Date

Office Use Only

  • Person to cost for:

  • Date:

  • Time Taken:

  • Person to cost for:

  • Date:

  • Time taken:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.