Adjustments Request

If you experience any difficulties with completing this form, please contact us via disability@surrey.ac.uk.

* indicates a required field

Register and Request Support

There is a wealth of support Disability & Neuroinclusion can offer at the University of Surrey.

Please complete the form below in as much detail as you are comfortable providing so that we can best advise and support you.

Please note: This form only allows one submission per student. If you need to make a subsequent request or add further information, please contact disability@surrey.ac.uk.

Your StatusRequired *

Current student

If you are a current student at the University of Surrey, you are unable to use this form. Please contact disability@surrey.ac.uk.

Section 1 of 7

Student details

First NameRequired *

Preferred Name

Last NameRequired *

Student IDRequired *

University Reference Number (URN)
The URN is a 7-digit number starting with a 6 or a 7. If you have not received your URN or are not aware, please email disability@surrey.ac.uk.

Level of StudyRequired *

Please enter your level of study

CourseRequired *

Please enter the full name of the course you have applied for.

EmailRequired *

Phone Number

Diagnosed disability falls into the following categoryRequired *

You may pick multiple selections.

Where possible, please select the most specific diagnosis available rather than a parent category. Use the arrows on the right-hand side to expand each category.

If you are awaiting a diagnosis or cannot find an appropriate option, please select Awaiting diagnosis or Other, as appropriate, and provide further details in the box below.

Please provide details of your diagnosis, working diagnosis or disabilityRequired *

Please tell us how your condition impacts you. If you are awaiting a diagnosis or assessment, please provide as much information as possible.

Please provide details of any previous exam and/or learning arrangements support at school, college, or another University. Required *

Have you got evidence of your disability, diagnosis, or previous exam adjustments?

This could be one of the following:

A diagnostic report
A JCQ Form 8 (you can request this form from your previous school/college)
An EHCP
A letter from a doctor or medical or clinical specialist that confirms either a diagnosis or the impact of your condition – this needs to be signed, dated and on headed paper

Please note:

Without evidence, we may not be able to offer all adjustments requested.

Section 2 of 7

Academic adjustments

Do you need to apply for adjustments in exams and/or lectures?Required *

Do you need to apply for adjustments in exams and/or lectures? Yes Do you need to apply for adjustments in exams and/or lectures? No

Exam adjustments

Use the options below to select the exam adjustments you have had in place previously. Please note that an Adviser will review your request and if they feel further supporting information is needed before agreeing to these adjustments, they will contact you.

Extra time

Other extra time

Please specify.

Rest breaks

Rest breaks provide you with the option to pause your in-person timed written exam. For online exams, you are provided with extra time.

Other Rest break

Please specify.

Room adjustments

Where you have in-person exams and require to be in a smaller room, select the relevant option below.

Reader

If you select Use of reader assistive technology, you will need to bring your own laptop to your exam with your reader software installed and ready to use.

In-person reader
Use of reader assistive technology

Scribe/computer

If you select Use of dictation software, you will need to bring your own laptop to your exam with your dictation software installed and ready to use.

In-person scribe
Use of dictation software
Use of a computer

Do you require the use of a PC for MCQ or SAQ exams?

If you selected Use of a computer above, please confirm whether you require a PC for MCQ or SAQ exams.

MCQ – Multiple Choice Questions
SAQ – Short Answer Questions

Do you require the use of a PC for MCQ or SAQ exams? Yes Do you require the use of a PC for MCQ or SAQ exams? No

Coloured paper or specific font

If you require your exam paper to be printed on coloured paper or in a specific type or size of font, please detail below.

Do you need to bring any specific items with you to the exam?

Please note that you would be responsible for bringing these items with you to the exam. D&N can loan you an item but you must contact us before the exam to arrange this.

Other Specific Items

Please specify.

Any other exam adjustment(s) and notes

If you have any other exam adjustment needs not covered above, please detail these below.

Learning adjustments

Use the options below to select the learning adjustments you feel you need. Please note that an Adviser will review your request and if they feel further supporting information is needed before agreeing to these adjustments, they will contact you.

If you select "Other" for the response to any question, please detail in the box at the end of the section.

General adjustments

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Learning materials in a specific format

If you require learning materials in a specific format, such as in a specific font, size, or alternative such as electronic texts or Braille, please detail below.

Communication

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1:1 support in class

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Any other learning adjustment(s) and notes

Section 3 of 7

Summary of condition

If you would like us to include the details of your diagnosis, working diagnosis or disability on your list of adjustments, please can you confirm the wording you would like us to include:

Section 4 of 7

Consent

I understand that the Adviser will review my supporting evidence and the adjustments they are able to offer may differ to my request.

I understand that these adjustments will be added to the University system and distributed to my department and the Central Exams team.

I understand that these reasonable adjustments will need to be shared with the following relevant staff in order to be implemented:

Exams and Graduation
Timetabling
Internal academic staff
External visiting lecturers
Lab technicians
Health and Safety

If you have concerns about sharing your reasonable adjustments with any or all of these relevant staff, please do contact D&N directly. However, be aware that not providing full consent may mean it is not possible for all adjustments to be implemented.

I understand and agree to the above statements:Required *

Please note that if you choose not to accept, we may not be able to implement all elements of your request.

I understand and agree to the above statements: Yes I understand and agree to the above statements: No

Section 5 of 7

Medical needs

Do you have any medical needs which the university should be aware of?Required *

Do you have any medical needs which the university should be aware of? Yes Do you have any medical needs which the university should be aware of? No

Please can you provide further details:Required *

Might you need emergency support such as first aid or an ambulance due to your condition?Required *

Might you need emergency support such as first aid or an ambulance due to your condition? Yes Might you need emergency support such as first aid or an ambulance due to your condition? No

If you have ticked yes, we will contact you again and ask you to complete an additional form which allows you to provide more details on your medical condition.

Section 6 of 7

Mental health

Have you previously or are you currently experiencing difficulties with your mental health?Required *

Have you previously or are you currently experiencing difficulties with your mental health? Yes Have you previously or are you currently experiencing difficulties with your mental health? No

Please can you provide more detail:Required *

Are you currently or have you previously received any form of support for your mental health?Required *

This could include from or via your GP, via statutory services such as CAMHS or CMHRS, private therapy or counselling, or from the student support department at your school. As detailed above, please do not feel you have to disclose this information if you do not feel comfortable doing so.

Centre for Wellbeing

At the University of Surrey we have the Centre for Wellbeing. The Centre for Wellbeing offers a range of pastoral services to ensure that our students feel well and supported throughout their time at the University. They are not a clinical service provider, but offer advice and support for mental, emotional and psychological issues, as well as signposting to clinical services.

https://wellbeing.surrey.ac.uk/centre-for-wellbeing

Section 7 of 7

Disabled Students' Allowance (DSA)

The Disabled Students' Allowance (DSA) is funding that helps to contribute to any additional costs a student might incur during higher education study as a direct result of a disability.

DSA is available in addition to your other student finance loans or grants and does not need to be repaid.

The funding is not a loan and not counted as income when working out whether you are entitled to benefits or Tax Credits. The amount you’ll receive depends on your individual needs and is not based on your income, nor that of your parents or partner.

Have you applied for the Disabled Students' Allowance?Required *

Have you applied for the Disabled Students' Allowance? Yes Have you applied for the Disabled Students' Allowance? No

Applying for DSA

There are many things that the Disabled Students Allowance can contribute towards, depending on your individual needs. This includes:

Specialist Equipment e.g. computer hardware and software
Non-Medical Helper support such as one-to-one tuition
Extra travel costs incurred due to your disability
Miscellaneous expenditure such as the cost of extra printing
Other disability-related costs of studying

If you have already applied for Student Finance: Sign in to your account to start your application. This should be on your ‘to-do list’. If not, select ‘change your circumstances’ to apply. You will need to provide copies of your medical evidence at this point.

If you do not need Student Finance, or if you applied by post, you can use the DSA paper application form available here:

DSA application forms

If you are eligible for Disabled Students' Allowance, you will receive an approval letter from your Funding Body. This could take around 6 weeks to arrive and is known as your DSA1 letter.

The next step is to arrange to attend a Needs Assessment at a location of your choice.

Following the Needs Assessment, the assessor will write a Needs Assessment Report, detailing all the recommended support, as discussed during the assessment.

After the Funding Body has made a decision on your recommendations, you will receive a DSA2 Letter which will outline exactly what equipment and support has been approved. The letter also includes the contact details of each of the support providers so that you can arrange for your recommendations to be implemented.

Upload your evidence

Upload supporting document(s)Required *

Provide evidence of pre-existing conditions and/or any other evidence that supports your application, e.g. hospital letter or treatment letter.

Drop files here to upload