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Pre-assessment questionnaire

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Please complete the pre-assessment questionnaire below.  If you need assistance or have a query please telephone 01782 295716 or 01782 295717.

  • Your details
  • Name
  • Home address
  • Term time address
  • Name of your funding body
  • Your course
  • Mode of study
  • Level of study
  • Your disability
  • What are the main difficulties caused by your disability? (Please tick all that apply)
  • Do you have an Education, Health and Care plan?
  • Your computer
  • Further support
    Details of any other support you may receive
  • Are you in receipt of Disabled Living Allowance (DLA) / Personal Independent Payment (PIP)?
  • If yes, do you have a Motability Car?
  • Permissions
    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 more information about your course. We may need to disclose your identify in order to gain accurate information.
  • Can we contact your Disability Officer?
  • Can we contact your course leader?
  • Observation of assessments: from time to time we need to set up observations of assessments for quality assurance purposes and for training of new assessors. Please check the box to agree to this.
  • The Staffordshire Regional Access Centre will securely store and process your information manually and electronically and will only share it with relevant personnel for the purpose of your needs assessment. Please check the box to agree to this.
  • The Staffordshire Regional Access Centre
    We are continuously working to improve and develop the service we provide and it would be really helpful to know:
  • Privacy statement
    This information will be submitted to your funding body with your needs assessment report. The information will be held on file by your funding body should they need to refer to it when authorising your DSA support.

    Staffordshire University ensures information is stored and handled in accordance with the data protection law. Please read our data protection policies for more details.