Keynes House, Trumpington Street,
Cambridge CB2 1QA
Email: disability@admin.cam.ac.uk
Website: www.cam.ac.uk/disability
Student Information Form
The information on this form helps the Disability Resource Centre (DRC) to work with you and
your College and Department/Faculty to arrange your academic-related disability support.
Please complete as much of this form as possible and return it to the DRC (contact details
above). It may not be possible to start the process of setting up your support until this
form and supporting evidence have been received.
This form is available in alternative formats on request, including Braille and large print.
Guidance notes and an electronic version of this form are available at
www.cam.ac.uk/disability-offer.
Section A: Your personal details
First name
Surname
Date of birth
Email address
Course
Year of entry
College
A1. Nature of your disability or medical condition (please tick all those that apply)
You have a social/communication impairment such as Asperger syndrome
You are blind or have a visual impairment
You are D/deaf or have a hearing impairment
You have a long standing illness or health condition such as cancer, HIV or epilepsy
You have a mental health condition, such as depression, schizophrenia or anxiety disorder
You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
You have physical impairment or mobility issues
You have a disability, impairment or medical condition that is not listed above
You have two or more impairments and/or disabling medical conditions
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Section B: Confidentiality Agreement
Once you have read and understood Section E: DRC Confidentiality Policy at the end of
this document, please complete and sign the following Confidentiality Agreement.
I have read and understood the DRC Confidentiality Policy and give the DRC full
disclosure to hold and pass on relevant information, as appropriate.
I have read and understood the DRC Confidentiality Policy and give the DRC restricted
disclosure to pass on relevant information to the following identified groups only:
College
Funding Body
Department/Faculty
Other (please specify):
Sign here:________________________
Print name:
Date:
__________________
________________
It is acceptable to return a signed electronic copy of this form by email.
Section C: Your disability-related funding
Any sources of funding you have applied for:
Disabled Students’ Allowances (e.g. Student Finance England)
Research Council Grants (please specify Research Council):
International Disabled Students’ Fund
Other (please specify):
If you have not applied from any sources of funding, do you intend
Yes No Unsure
to make an application?
Your Student Finance Customer Reference Number or Research
Council Grant Reference (if known)
Do you have any questions or concerns about your disability-related funding you would like us
to answer?
More information on funding is available online at: www.cam.ac.uk/disability-finance
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Section D: Your disability-related study support requirements
D1. Please tell us more about your difficulty and how it affects your studies
Please also attach relevant supporting documentation to this form (e.g. Educational
Psychologist’s assessment, audiology report, or medical letter).
D2. What support did you receive at school, sixth form, college or other further
education or higher education institution? (please tick all those that apply)
None
Learning Support / Study Skills
Technology and equipment support
Examination arrangements, e.g. extra time, use of a PC
Hand-outs in alternative formats, e.g. colour paper / Braille / large print
Note-taker
Please provide any additional information:
D3. Lectures and supervisions
Which of the following adjustments would you find useful in order to attend and
participate in lectures and/or supervisions? (please tick all those that apply)
Permission to record lectures
Lecture hand-outs in advance
Lecture hand-outs in alternative format, e.g. colour paper / Braille / audio / large print
Reading lists in advance
Reading lists in alternative format, e.g. colour paper / Braille / audio / large print
Extended deadlines
Assistive Technology equipment, e.g. laptop, digital recorder
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Reserved seating in lecture theatre near front / light source / window / exit
Loop / infrared system for hearing aid
Regular rest breaks
Please provide any additional information:
D4. Human Support
Which of the following types of human support would you find useful in order to
support you with your course? (please tick all those that apply)
More information is available online at: www.cam.ac.uk/disability-humansupport
1-1 Specialist Study Skills sessions, e.g. essay structuring and planning
1-1 Specialist Mentoring, e.g. time management
Note-taking and/or Recording, e.g. in lectures
Practical Assistance
Library Assistance
An amanuensis (scribe)
Proofreading support
Transcription support, e.g. of recorded notes
Orientation support
Electronic note-taker / interpreter / lip speaker
Please provide any additional information:
D5. Libraries
Which of the following adjustments would you find useful in order to access and use
libraries? (please tick all those that apply)
Extended loan periods
Photocopying / scanning of required texts
Assistive software to scan or allow access to printed materials in an alternative format
Specialist lighting or proximity to window
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Permission to bring food/drink or medication into restricted areas
Reserved seating
Please provide any additional information:
D6. Practicals
Which of the following adjustments would you find useful in order to attend and
participate in practicals? (please tick all those that apply)
Extension to time available
Permission to record verbal instructions
Loop / infrared system for hearing aid
Regular rest breaks
Reserved seating near front / light source / window / exit
Please provide any additional information:
D7. Examination Access Arrangements
Do you have any requirements in the following areas? (please tick all those that apply)
Please see the DRC website for further details and important information about the application
process for exam access arrangements: www.cam.ac.uk/disability-exam
Extra Time
Use of a word processor
Examination paper in alternative format, e.g. colour paper / Braille / audio / large print
Loop / infrared system for hearing aid
Examinations in a separate room with one-to-one invigilation
Specialist ergonomic seating
Rest or nutrition breaks
Please provide any additional information:
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D8. Physical Access & Accommodation
Do any of the following cause you difficulties? (please tick all those that apply)
Stairs, e.g. handrails, spiral staircases or long flights
Walking long distances within large buildings
Walking long distances between colleges, departments, libraries etc.
Evacuating a building quickly in an emergency
Swipe card entry systems
Signage
Opening heavy doors
Navigating cobbles / narrow pavements
Will you require any of the following?
Wheelchair access
Level access
Specialist ergonomic seating
En-suite accommodation
Accommodation with adapted bathroom
Ground floor accommodation
Vibrating / visual fire alarm
Other accommodation requirements, e.g. quiet room / good light / a separate fridge
An additional room for your carer or personal assistant
Accommodation suitable for an assistance dog
Please provide any additional information:
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If there is any further information you would like to provide, please detail below.
Section E: DRC Confidentiality Policy
Your written consent is required for the DRC to hold and disclose your information to relevant
members of staff at the University of Cambridge.
The DRC works under the terms of the Data Protection Act (1998) and the Equality Act (2010).
Information relating to physical or mental health constitutes sensitive personal data. Under the
Data Protection Act (1998), explicit permission from the data subject must be sought before
this type of information is passed on to a third party, unless there is a legal obligation to
provide the information. Please ask your Disability Adviser if you have any questions
concerning the data we keep. Information about how your information will be stored is
available on the DRC website at www.cam.ac.uk/disability-sif.
You may choose to give either full disclosure or restricted disclosure to the DRC. This is
explained below. You may contact us at any point to change your level of disclosure.
Who will you share my information with if I give FULL DISCLOSURE?
The DRC may need to disclose your information to certain people in order to help support you.
This information will only be shared where necessary and on a ‘need to know’ basis. We define
‘need to know’ as sharing sufficient information to help set up support and only with people
involved in that process. We always ask that the people with whom we share your information
respect your confidentiality and do not pass your information onto anyone else unless they are
also involved in your support.
Those with whom the DRC may share your information can include (but is not strictly limited
to): your Tutor/Tutorial Office, Director of Studies, College Nurse, Academic Department,
Graduate Supervisor, Board of Examinations and Funding Body. The DRC may also share
student data with other University bodies, such as the Careers Service, for recruitment,
statistics, and monitoring purposes.
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The DRC may also need to request further information about your additional support
requirements from your GP, Consultant, Educational Psychologist, previous education
provider, or Funding Body (e.g. Student Finance England) where appropriate. We respect your
confidentiality and assure you that any information shared will be handled in a sensitive and
discreet manner.
We will not speak to your parents/legal guardian about you without your express permission.
Who will you share my information with if I give RESTRICTED DISCLOSURE?
You may choose to restrict the disclosure of your information. You can decide to restrict to all
individuals outside the DRC or to allow information only to certain individuals. If you choose
to do this, please be aware that this may limit the level and type of support the
University and college can provide for you. We may not be able to speak to the relevant
people to request reasonable adjustments to be made. This could include your Funding Body
and any Disabled Students’ Allowances applications you may have made.
If you would like to discuss what adjustments can be made in such circumstances, please
contact your Disability Adviser.
In certain exceptional circumstances (such as where there is an immediate and serious threat
to your personal safety or to the safety of others), we may disclose your information without
your consent.
Fitness to practise
If you are on a professional course such as medicine or veterinary medicine, you will be
subject to additional fitness to practise requirements prescribed by the professional body. This
includes a requirement to disclose information about a disability. Restricted disclosure may
later compromise your professional registration. If you are unsure whether or not this applies
to you, or are concerned about the implications of disclosing a disability, please contact your
Disability Adviser.
Once completed, please return this form to:
Disability Resource Centre
Keynes House
Trumpington Street
Cambridge CB2 1QA
Or email to: disability@admin.cam.ac.uk
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