Fillable DSA Disabled Students Allowances Disability Evidence Form (University of Northampton)

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DSA Disabled Students Allowances Disability Evidence Form (University of Northampton)

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The DSA Disabled Students Allowances Disability Evidence Form (University of Northampton) form is 3 pages long and contains:

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1 SFE/DSAEVID/B
/
/
DSA
Disabled Students’ Allowances
Disability Evidence Form
About this form
To get DSAs a medical professional (for example, your GP) needs to provide
information about your disability on this form.
Don’t complete this form if you have a specific learning difficulty. You need to send us
a diagnostic report from a suitably qualified psychologist or specialist teacher instead.
What you need to do
You need to complete your details in section 1.
Then pass the form to the medical professional to complete, sign and date the
declaration.
Once they have completed the form, make sure you return it to the address on
page 4.
You should keep a copy of this form for your own records. You may require it later
for your needs assessment.
Section 1
Personal details
1.1 Customer Reference Number
1.2 Personal details
Title
Mr Mrs Miss Ms
Forename(s)
Surname
Date of birth (DDMMYYYY)
Now pass this form to the medical professional.
2
SFE/DSAEVID
Stamp here
Section 2
Medical professional details
Sections 2, 3 and 4 should be completed by a medical professional
To support the student’s DSAs application we need you to give us information
about the nature of the student’s disability. Complete the rest of the form, read,
sign and date the declaration, then pass the form back to the student. As the
student can’t reclaim any charge made for completing this form via DSAs, we ask
that it is provided free of charge.
To find out how we’ll use the information you provide go to
www.gov.uk/studentfinance to read our Privacy Notice before completing
this form.
2.1 Your details
Full name
Job title
Certificate or registration number
(GMC, HCPC, NMC)
2.2 Practice or organisation
details
Where possible use your
practice or organisation’s
stamp.
Type of practice or organisation
GP Practice
Primary Care Team
Secondary Care
Team
Hospital
Other (give details below)
Name of practice or organisation
Address
Postcode
Contact number
2.3 What is your professional
involvement with the student?
You only need to give details if this
isn’t apparent from your job title.
3 SFE/DSAEVID
Section 3 About the student’s disability
In your professional opinion, complete the following questions about the
student.
3.1 Does the student have
a physical, sensory or
mental disability which
has a substantial* and
long term adverse effect
on their ability to carry out
normal day-to-day activities
(including education)?
To be considered long term,
the effect of the disability must
have lasted or be likely to last
at least 12 months or for the
rest of the student’s life.
*more than minor or trivial.
No
Yes - give details
3.2 Diagnosis / working
diagnosis (including any
relevant dates)
If it’s not possible to give
either, explain why.
Date of diagnosis (DDMMYYYY)
Section 4 Medical professional declaration
Sign and date below to confirm that to the best of your knowledge the information
you’ve provided is true and complete.
Medical professional signature
Today’s date (DDMMYYYY)
Now pass this form back to the student.
SFE/DSAEVID 4
Additional information
Do you need help?
If you have any questions about your
application you can email us:
DSA_team@slc.co.uk
You should include your Customer
Reference Number on any emails you
send.
Do you need this form in braille,
large print or audio format?
Email us:
brailleandlargefonts@slc.co.uk
or call us on 0141 243 3686
Please note the above email address
and telephone number can only deal
with requests for alternative formats of
forms and guides.
Before you send your form
We recommend you keep a copy of
this form for your own records. You
may require it later for your needs
assessment.
Where to send your form
Once the form is complete you can
email it to:
DSA_team@slc.co.uk
You can also send it by post to:
Student Finance England
PO Box 210
Darlington
DL1 9HJ
Remember to pay the correct postage
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DSA Disabled Students Allowances Disability Evidence Form (University of Northampton)

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Completed 4 February 2021

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