MB ChB 2016 Cohort Additional Information for Clinical Skills Training A condition of your registration at Warwick Medical School is that you inform us of anything that has in the past or currently affects your ability to learn, or may influence your performance during the course, including interacting with patients. Returning this completed form will allow Warwick Medical School to instigate any necessary support systems. You need to consider the following: Vision – do you have sufficient vision to be able to pass the driving test visual requirement, and read handwritten and typed text, placed at an appropriate distance, without visual aids other than spectacles or contact lenses, and that you can understand the word. Specific Learning Difficulty (SpLD) – such as dyslexia or dyscalculia must be declared. The University will make an assessment of any declared SpLD and if deemed necessary appropriate help can be organised. Hearing – that you are able to hear, using a fitted hearing aid if required, such that you can understand a softly spoken child or elderly patient, and that you can hear what is said when using a conventional telephone. Fit or seizure – have you experienced either in the last year. Are you physically able to write legibly by hand. Do you have a physical disability that is likely to prevent you from successfully completing training on how to attend to a patient who has collapsed to the floor, which requires you to turn the patient into a safe position. Blood borne viruses – if you do not acquire the necessary immunity you may still be admitted to study but be excluded from exposure prone procedures. Other problems e.g. allergies, diabetes, depression Do you have any of the conditions above? YES / NO Do you have any other condition affecting your physical or mental health which may require additional learning support to be put in place? YES / NO Do you have a current or spent criminal conviction(s) and/or caution(s) contained in a DBS check? YES / NO If YES to any please give details below: I declare that the above information is true and complete to the best of my knowledge and belief. I agree that if I accept a place to study at Warwick Medical School that I may be invited to attend a medical assessment by an Occupational Health Advisor / Physician. Surname: First Name: UCAS Number: University Number: Signature: Date: Please return to: Mrs Ann Malczewski, Medical Teaching Centre, University of Warwick, Coventry, CV4 7AL by 31 May 2016.