Application for Disability Related Support - Student Disability Service

The information you provide in this form will help to identify your support requirements and provide the initial information required to begin the production of a Reasonable Adjustment Plan (RAP) appropriate to your individual needs.

1. Preferred Name (this will be used in all correspondence with you and those implementing support for you)*
2. Legal Name (This should be your full name in which you are formally known to the University of Birmingham)*
6. Date of birth*
e.g. BA English or PhD Chemistry
8. Level of Study*
10a. Please tick all relevant Disabilities / Health conditions below:*
Do you currently use a screen reader
10c. Do you provide your consent for us to share information about your disability with your Wellbeing Officer and staff who will be supporting you in your department on a need to know basis*

A PEEP is a bespoke plan for individuals who may not be able to reach an ultimate place of safety unaided, or within a satisfactory period of time in the event of an emergency. Please consider the following questions:

11e. On the basis of your answers to 11a - 11d we would recommend you undertake a PEEP or discuss this further. Please indicate below

You are responsible for drawing attention to changes in circumstance that should prompt a review. If you decide a PEEP is not currently required but circumstances change you are responsible for informing your Disability Adviser / Wellbeing Officer to request this is implemented.

Please provide further details about possible support requirements or any adjustments you may have received previously. (This can include possible areas such as accommodation adjustments, exam arrangements, personal care requirements (this will need to be arranged through alternative providers, we advise you how to access this, if needed), mobility support etc)

(Please note that arrangements that were in place at a previous institution may not necessarily be made at UoB)

13a. Have you applied for University accommodation?
13b2. How does your disability affect your studies?

Please attach appropriate evidence below (this will be required before any adjustments can be put implemented). Further guidance about appropriate evidence can be found at 

(please note prescriptions, JCQ Form 8 from school and appointment letters will not be accepted as appropriate evidence).

We are aware that it can be difficult to obtain appropriate evidence. If you are having difficulties obtaining evidence please contact us for further advice by emailing

No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

Disabled Students' Allowance (DSA) is funding available to eligible students to cover some of the extra costs you may incur because of a mental health problem, long term illness or any other disability.

If you haven’t applied for Disabled Student’s Allowances, further information about the process and eligibility criteria can be found at

If you have already undertaken a needs assessment, please attach a copy of your report below:

No File Chosen
File uploads may not work on some mobile devices.


Accessing support through SDS requires us to hold information in relation to your disability. This could include (but not limited to) registration forms, evidence, DSA forms, correspondence and Reasonable Adjustment Plans.

Dependent on your individual needs your information may need to be shared with the following people within the institution as appropriate: relevant staff within your College, Examinations office, Accommodation, Library services, Timetabling etc. This information will only be shared on a need to know basis to ensure that your support can be implemented.

Where additional support is required, information may also need to be shared with external providers such as assessment centres or support providers to help facilitate support.

For more information about how your details may be shared please visit

22. Do you agree for information concerning your disability and individual support requirements to be held by the Student Disability Service?*
23a. I agree to the following people need to be notified in order to implement a Reasonable Adjustment Plan (RAP) for me: Wellbeing Officer / Leads and administrators working to implement my adjustments, Reasonable Adjustments Co-ordinator, Examinations Office, Estates Office, Library Service, Personal tutor(s), Course leader(s), Lecturer(s), Placement Supervisor/Mentor, Accommodation Office. *
23b. I agree to relevant information being shared within the University of Birmingham and with other relevant, appropriate staff external to the University (including the Assessment Centre, Funding Body and Support Worker(s) on a need to know basis, where necessary to meet your support needs?*


Triage actions required

1. Check that the details entered by the student are accurate against the Banner student record system. Update the form to ensure that the full course title is displayed, the correct ID number is used (even if the student is still an applicant) and that the correct College and organisation is used (this is critical as it will drive communications to the right Wellbeing team).

2. If the student has entered a personal email address in the form ensure that this is recorded in GOAEMAL in Banner.

3. Enter the student's UoB email address in the field provided in the triage section (if this is entered in the email field by the student you will need to duplicate this here), If the student does not yet have a UoB email copy the value from the student email field into the UoB email address field.

4. Go to GOAMEDI in Banner and enter the disability code provided by the student.  If the student has indicated that they are in receipt of DSA populate this information in the field provided.

5. You will need to enter the contact email address for the students Wellbeing Officer in the field below - this will drive all comms to the students College.  To find their email address go to

24. Student's Name recorded in BANNER
Programme Start Date
Only to be used for Joint Honours Students
27. Is the email address provided a School or College email address?*
28. New ./ Current Student*
Is the student new to the University
29. Select Evidence Received*
31. Evidence Rejected 1
32. Evidence Rejected 2
33. Evidence Rejected 3
34. Evidence Rejected 4
36. Triage Outcome*

Evidence pending

No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
42. Evidence Outcome

Approve Evidence 1

43. Approve Evidence?*

Evidence pending - rejected by SDS

No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
61. Evidence Outcome 2

Approve Evidence 2

62. Approve Evidence?

Assign to disability advisor

Applicant Waiting Room

Student Waiting Room

RAP Information

76. RAP Created*
78. Disability Type
78 a. Social / Communication
78 b. Blind / VI
78 c. Deaf / HI
78 d. Long standing illness or health condition
78 e. Mental Health Condition
78 f. Specific Learning Difficulty
78 g. Physical impairment or mobility difficulty
To be shared with Wellbeing Officers Only

School or Department Actions

79. Reasonable Adjustment Co-ordination*
81. Coursework*
  • To minimize the risk of misinterpretation, the opportunity should be provided for the student to seek additional clarification and/or discuss outline assignment plans with tutors. PGA staff must ensure that students know how to access this support and are clear about the number of sessions available.   

  • If extensions are needed due to disability-related reasons, PGA staff should discuss the mechanisms for this with the student.

  • It may be advisable to create an academic plan to enable the student to manage their deadlines.

  • Accommodations may be needed for presentations, for example extra time to prepare when on a residential course.
83. Presentations*
85. Group Work*
87. Practical Sessions*
89. Lectures / Tutorial*
92. Placements / Year in Industry*
94. Fieldwork & Residentials*
95. Study Abroad*
97. Research*
99. Viva*
101. Non Medical Helper support*

Timetabling & Estates

E101 Do you need to notify Estates
103. Are timetabling adjustments required?*
104. Timetabling*

Exam Adjustments

107. Are centrally managed exam adjustments required*
109. Specific Exam Adjustments*
111. Oral exams*
112. Listening exams*
113. OSCEs*
114. Deferring Assessments*
  • It is the PGA’s responsibility to ensure that the student is fully aware of when and where their examinations will take place. The PGA is responsible for organizing the exam venue and providing an invigilator/ reader/ scribe. The student has been advised that their future exams will take place at the Belfry.

  • The student is entitled to 35% extra time per hour online tests/class test/examinations. If there are more than 3 hours of exams scheduled in one day consideration should be given to splitting the exams over two consecutive days

Library Adjustments

116. Are library adjustments required?*
117. Library adjustments*

Assistive Technology Booths (ATBs)

N.B. Software equipment and software available in ATBs – ATB access ONLY to be recommended for use of software / equipment – not for meetings / sleeping. Students should be made aware that they are entitled to 3 hours per day. Extensions can be requested through Library Services who will discuss requirements with the student based on need and availability, and look to confirm with disability services.

Technology available in ATBs

TextHelp Read and Write
Ergonomic mouse
MindJet Mind Manager
High contrast keyboard
Natural light lamp
Tactile graphic printer
Index Brailer
Claro, View, read, screenreader
Flatbed Scanner
Dolphin easy convertor
Pearl Scanner
Tv Magnifier

Accommodation Adjustments

Adaptations required to accommodation

122. Are accommodation Adjustments Required*
123. Is the student a manual / electric wheelchair user?
125. Does the student have specific bathroom requirements?
e.g. wet-room, grab rails, shower seat
127. Does the student have specific kitchen requirements?
e.g. lowered work tops, sink, hob
129. Are automatic doors required?
130. Is a hoist required?
131. Does the student have specific bedroom requirements?
e.g. adjusted electric points, light fittings, room for specialised furniture such as hospital bed, hard flooring

General Accommodation Arrangements

133. Room Type
134. Food / Meals
e.g. requires ground floor, higher floor
e.g. close to campus, needs car parking, lift access, quiet environment
137. Deaf alerter required?
138. Fridge required?
139. PEEP required?
140. Room for PA required?
141. Assistance Dog required?

Student Response

143. Student Response to RAP*
copy the students response to the RAP into this field.

Amend and send RAP

Send amended RAP

Keep Rap Open

Note: pressing submit will permanently close this form!