Undergraduate Form

Questionnaire to Determine Support Requirements 2019/20

1. Personal Details

Please enter your details











2. Course Details

Names of courses applied for at Queen’s (eg BSc Psychology). Please list all courses for which you have submitted an application, even if you have not received an offer.









3. Disability Support Requirements

Part a)

Nature of Disability (please check the box as appropriate).



Part b)

Please provide as much detailed information as possible about your disability and how it impacts on your studies.


Part c)

Please outline what educational support arrangements have been made for you to date.

4. Specific Requirements whilst at University

Should you be successful in obtaining a place at Queen's, you will be invited to meet staff from Disability Services which will enable you to discuss your individual requirements. However, to allow us to have some understanding of what support you may require at this time, please outline the following:

Support requirements for study, eg notetaker, materials in alternative format etc.

Support requirements for examinations, eg extra time, scribe etc.

Support within placements, field work, laboratories etc.

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.

If you are applying for Queen’s Accommodation and require any adjustments please contact Queen's Accommodation direct on accommodation@qub.ac.uk


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.