DSA Pre-Assessment Information Form
The purpose of the DSA study needs assessment is to determine what difficulties you may face with your study
due to your disability and to consider what support can be provided to overcome those difficulties. In order to
get the best outcome from this assessment, we require the following information in advance. This will enable us
to do any prior research needed, so that we can consider the full range of support available.
About you
Surname:
First Name(s):
Date of birth:
Email:
Title:
Home address:
Term time address (if different):
Telephone Number:
Mobile Number:
Tell us about your Local Educational Authority (LEA); or other funding provider:
Institution Name:
Student Number:
Telephone Number:
Address:
Contact Name in the LEA / NHS Department (if known)
Email:
If you have been previously assessed for DSA funding, please give the date and details. Please attach a copy
of the report, if available
Tell us about your disability / medical condition(s)
What type of disability are you being assessed for (you will find this in your funding body approval letter)?
What are the main difficulties caused by your disability and how are your learning or study support
requirements effected?
Pre-assessment January 2016
About your University or College
We will not disclose your identity to your University / College without your permission. However, it may be
helpful for us to contact your disability officer / course leader for information regarding your course. Please
confirm if you are happy to give your permission.
I am happy to give permission for you to contact my university / college: Yes / No (delete as appropriate)
University / College Name:
Address:
Disability Officer / Contact:
Name:
Tel:
Email:
Course Title:
Course start date:
Course end date:
Award (BA, BSC, PhD):
Course Leader / Named contact:
Course length:
Study Intensity (full or part time):
Course Leader Email:
Course Leader Tel:
Tell us about your disability / medical condition(s)
What type of disability are you being assessed for (you will find this in your funding body approval letter)?
What are the main difficulties caused by your disability and how are your learning or study support
requirements effected?
Tell us about any previous educational support you have received:
Non-medical helper support with study
activities
Special examination arrangements
Assistive technology (computer, software)
Ergonomic study support equipment
Pre-assessment January 2016
What equipment do you have regular access to (computer, tablet, smartphone). Please provide details including
the make and model of each.
Note: Please feel free to bring along any mobile/tablet equipment you use to your assessment.
Student Declaration
The cost of your assessment is £660 and will be met from your DSA. We will invoice your LEA or awarding
body directly to claim our fee.
By signing this form you are agreeing for the Access Centre to arrange a DSA assessment on your behalf; you
are giving your LEA or awarding body permission to release funds from your DSA to pay for the assessment.
If we make an appointment for you to be assessed and you fail to keep that appointment we may at our
discretion recover our costs from your LEA.
Student signature:
Date:
Please return the completed form together with:
 Medical evidence i.e. GP letter, medical reports.
If you are Dyslexic, you will need to provide an up to date Psychology report.
 A copy of your funding body eligibility letter DSA 1 – Next steps to get your Disabled Students
Allowances 2015/2016
All information should be emailed to access-centre@open.ac.uk as soon as possible.
What happens next?
Providing you have sent the completed pre-assessment form and supplementary documents to the Access
Centre, we will contact you within 2 working days to arrange an appointment with one of our experienced
assessors, to take place on a date and time to suit you.
Pre-assessment January 2016
Important - please read carefully
Data Protection
We are committed to the Data-Protection principles of good practice for handling information. All personal
information is held securely and we will only transfer data on a ‘need-to-know’ basis so that we can support
the services offered to you. Due to the nature of the Access Centre, we will share your personal information
with Assessors / Trainers contracted by the Centre and third parties such as your funding body, in order for
relevant services to be provided to you. All information is shared under strict contractual and / or confidentiality
obligations.
As soon as you contact us, we will create a record in your name. To that record we will then add information
we collect, including information that you give us at point of first contact with the Centre; through the
appointment process; when we are notified of your DSA award and any supplementary or re-assessment
requests made. This includes information sent directly to us, for example from your Funding Body or HEI
Disability Advisor.
We will use your personal information to process your application, perform your assessment and provide you
with necessary services.
From time to time we may want to carry out research to help us plan and improve our services. We (The Open
University) may contact you ourselves or ask outside research agencies to do so on our behalf. We will also
use the information you provide to produce anonymised statistical information.
Telephone calls may be recorded to make sure we have carried out your instructions correctly and to help us
improve our services through staff training.
Security
We take security very seriously. All staff are made aware of the security procedures they must follow when
handling personal information. Information is protected from unauthorised access and we are confident no one
will be able to access your personal information unlawfully. We also protect information which is being
transferred. As long as your web browser supports the Secure Sockets Layer (SSL), any personal information
transmitted from your browser to our web service, or from the service to your browser, will be encrypted to
make it unreadable. Please note that internet email is never a 100% secure way of communicating. By using
it, you agree that you will send any information by email at your own risk.
While we will take all reasonable precautions to make sure that other organisations who we deal with have
good security practices, we are not responsible for the privacy practices of those organisations whose
websites may be linked to our service.
Further Information
The data controller for your personal data is The Open University. If you have any questions about data
protection policies and procedures or if you want a copy of the personal information the University holds about
you, please email data-protection@open.ac.uk or telephone 01908 653994.
Pre-assessment January 2016