Please return this form to: Admin@ACCESS-CENTRE.xx.UK or Fax to: XXXXXXXXX; Post:
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.
STUDENT DETAILS Name:
Home Address:
Date of Birth
Term Address (if known):
Mobile:
Tel:
Email:
COURSE DETAILS (* delete as appropriate)
Full/Part Time*
Post/Under Graduate*
FT PT
PG UG
Year of Study
Course Ends
INSTITUTION DETAILS
Disability Team
Named Contact (if known)
Tel:
Email:
DISABILITY DETAILS
Course Leader
Tel:
Email:
Named Contact: (if known)
1. What are the main study difficulties caused by your disability/condition?
Please indicate below the areas you have difficulties with (please tick any that are relevant to you)
Handwriting
Reading speed
Typing
Reading accuracy
Mobility
Reading comprehension
Concentration
Spelling
Time management
Mood
Physical health
Vision
Processing speed
Grammar
Organisation
Motivation
Energy levels
Hearing
Short-term memory
Structure in writing
Note taking
Confidence
Coordination
Communication
2. What type of support have you received in the past (e.g. in school / college)?
3. What type of support has been most helpful to you in your previous study?

4. What type of equipment do you already own that might be adapted for use in your study?
Please list.
5. Do you currently use any assistive technology software? Please list.
Note: Please bring to your assessment any mobile phones / tablets / other mobile devices that you have, so that we can also consider software, apps and peripherals that are compatible with your equipment. Please also bring the make and model of any equipment that you are unable to bring with you, for example a PC.
4. If you have been previously assessed for DSA funding, please give the date and details.
Please attach a copy of the report, if available.
Student Name: Date:
Signature: