Questionnaire to Determine Support Requirements 2019/20 1. Personal Details Please enter your details Name Address* Post Code Telephone Mobile Email Date of Birth Postgraduate Application Number: 2. Course Details Names of postgraduate courses applied for at Queen's. Please list all courses for which you have submitted an application, even if you have not received an offer. Course a) Course b) Course c) Course d) Course e) Course f) 3. Disability Support Requirements Part a) Nature of Disability You have a social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder. Please Select Yes No You are blind or have a serious visual impairment uncorrected by glasses. Please Select Yes No You are deaf or have a serious hearing impairment. Please Select Yes No You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy. Please Select Yes No You have a mental health condition, such as depression, schizophrenia or anxiety disorder. Please Select Yes No You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D. Please Select Yes No You have physical impairment or mobility issues such as difficulty using your arms or using a wheelchair or crutches. Please Select Yes No You have a disability, impairment or medical condition that is not listed above. Please Select Yes No You have two or more impairments and/or disabling medical conditions. Please Select Yes No Part b) Please provide as much detailed information as possible about your disability and how it impacts on your studies. Your Disability Part c) Please outline what educational support arrangements have been made for you to date. 4. Specific Requirements whilst at University What specific support do you envisage you may have whilst studying at Queen’s? You will be invited to discuss your support requirements in greater detail if you are successful in obtaining a place at Queen's. 5. Support during placement, field work, laboratory work and similar environments Part a) Some courses may include placements, field work or a requirement to work within a laboratory setting. Please indicate if you have any additional support requirements within these settings as a result of your disability/medical condition.: Support requirements for study, eg notetaker, materials in alternative format etc. Part b) Do you envisage that you will require on-campus accommodation? Please Select Yes No If you have answered YES to this question, please indicate any disability-related requirement below. Do you require a ground floor room? Please Select Yes No Do you require an en-suite room? Please Select Yes No Do you require a room with a flashing fire alarm light? Please Select Yes No Do you require other accommodation? Please Select Yes No If Other Please specify Please note that answering YES to part 5b does not constitute an application for University accommodation. For information about accommodation, please contact the Elms Village: Telephone: 028 9097 4525Email: email@example.com The University Disability Services will ensure that personal data contained in this form will be used to plan appropriate support for you. It may be necessary for Disability Services to disclose appropriate and relevant details to other University departments to facilitate this process. I consent to information relating to my personal details, nature of disability and academic and support requirements being forwarded as outlined above. Please type your name below and insert the date if you agree with the disclosure of this information on these conditions. Student Name Date If you have any difficulties in this regard, please contact Disability Services for advice.