Questionnaire

Accessible Learning Support Online Form

Introduction

Thank you for taking the time to provide information to Queen's University Accessible Learning Support.

We are committed to ensuring that you receive the best possible support during your studies. To help us understand your needs, please complete this form as fully as possible.

If you were previously supported by Queen’s University Disability Services/Accessible Learning Support and are starting a new course, please contact us directly at accessiblelearning@qub.ac.uk instead of completing a new form.

At the end of this form, you will have the option to upload any documentation that outlines your disability or long-term condition. Supporting documentation is helpful for understanding your needs and identifying reasonable adjustments. It is also required for possible funded support. If you do not have supporting documentation, we encourage you to complete the questionnaire, as you may still be able to access support.

Based on the information you provide in this form, we may conduct a desktop assessment to recommend appropriate in-course support. A desktop assessment does not require an appointment - we will review your details and recommend reasonable adjustments to support your learning.

If you prefer NOT to have a desktop assessment, please select NO

Student Support Agreement

Accessible Learning Support and Student Wellbeing offer a range of specialist services to enable all students to have a positive learning experience. A specialist staff member can meet with you to listen to your issues, identify a range of possible options and ensure you have the right supports in place that meet your needs.

We know that confidentiality is important to you, and the University is committed to creating an environment where students are comfortable in seeking support. Student Wellbeing and Accessible Learning Support will hold and process your data in line with the University's Data Protection Policy.

Please be assured that all information we receive is treated sensitively and that we only disclose appropriate levels of information to relevant University staff and associated personnel. However, it may be necessary for us to share information with relevant third parties including health and social care professionals, parent and/or next of kin if there is a known or suspected risk of harm to yourself or others. There may also be occasions where we have a legal obligation to share information and you will be advised of this. If you wish to view more details about how and when we will use your data, please refer to the Student Privacy Notice.

If you are residing outside of Northern Ireland (NI), please note the delivery of our services will be undertaken in accordance with the laws and regulation standards in NI, and any disputes will be subject to NI law.

Agreement to Student Support

Please sign below to indicate that you agree to participate with support from Accessible Learning Support and Student Wellbeing, and the sharing of information on the above conditions.

Please note: You have the right to withdraw your consent to disclose information at any time. You can do this by informing us in writing to accessiblelearning@qub.ac.uk. Upon receipt of this request, a relevant staff member will make contact with you to discuss this further.

Signature

Contact Information

First name

Last name

Email (please provide your QUB email address if you have one)

Date of Birth

Mobile Phone

Telephone

Address Line 1

Address Line 2

Town

County

Country

Postcode

Preferred Pronouns (optional)

Have you previously been supported by Accessible Learning Support/Disability Services?

Please provide details of a Trusted Contact

This should be a trusted person over the age of 21, ideally living in the United-Kingdom">United Kingdom (UK). If you are living and studying outside NI, your trusted contact should be living in the same country that you are residing in.

Please be assured we will only contact this person if there are serious concerns about your wellbeing. However, it is recommended that you have a conversation with your nominated Trusted Contact to let them know that you have provided their details to the University.

Trusted Contact Name

Trusted Contact Phone

Trusted Contact Relationship

Trusted Contact Living in UK

Application

Are you a:

QUB Student Number

Applicant Type

Subject Area

Application ID (e.g. UCAS reference)

Course A

Intake Month (if known)

Course B

Application ID

Course

Disability Support Requirements

Disability Type

Please select any relevant categories

Social / communication impairment such as an Autistic Spectrum Condition

Blindness, or a serious visual impairment uncorrected by glasses

Deafness, or a serious hearing impairment

Long standing health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy

Mental health condition, such as depression, schizophrenia or anxiety condition

Specific learning differences such as dyslexia, dyspraxia or AD(H)D

Physical impairment or mobility issues, such as difficulty using limbs, or requiring mobility aids

A disability, impairment or medical condition that is not listed above

Details of your disability or long term condition

Please describe your disability or long term condition and how it impacts your studies. Consider aspects such as:

Concentration and focus
Managing fatigue or pain
Attending classes regularly
Participating in group work or social interactions
Any other relevant factors

Duration of your disability or condition

How long has your disability or condition affected you? Is it expected to be ongoing, or does it fluctuate over time? (NB: The Disability Discrimination Act states that a disability is long term if it has lasted, or is likely to last for 12 months or more)

Previous Educational Support arrangements (including access to online learning)

Outline what educational support arrangements, if any, you have had in the past

Additional Support

Please indicate any additional support you have accessed previously

CAMHS

Psychiatrist

Community/Voluntary

Psychologist

Counselling

SENCO

Family

Transitions Officer

Other Support

Specific Requirements Whilst at University

Please outline any support or adjustments that would help you succeed in your studies:

In-course (e.g. lectures, tutorials, group work, presentations)

Examinations and Assessments

Practical work such as placements, field work and laboratories

Anything Else You Would Like Us to Know?

Is there anything else that would help us understand your support needs? You can also use this space to let us know what you would like university staff to be aware of to ensure you receive the best possible support.

Supporting Documentation

Supporting Documentation Upload e.g diagnostic report, referral letters, GP letter

If available, please upload your documents here.

If you have multiple files, please place these documents in a zip archive before uploading.

If you have a single file larger than 64MB you should zip it before upload otherwise it will exceed the file size limit.

Selected files: 0 Total size: 0

Accessible Learning Support (formerly Disability Services)