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Health Professional Report
for Educational Adjustments
1
UNSW Equitable Learning Service
9385 4734
| els@unsw.edu.au
UNSW is committed to ensuring that all students are able to participate in all aspects of University
life. The information provided below will assist the Equitable Learning Service to develop
educational adjustments to support your studies. Use the form to provide Equitable Learning
Services with information about your disability, long term illness and or mental health condition.
NB: If you are providing a letter from your practitioner / health care provider instead of this form, it must
be current and include:
• Information on the condition
• nature of the condition – permanent /
temporary
• how your study may be impacted
• providers letterhead and / or
provider stamp
Section A: Completed by Student
Family name:
Given name:
Student number:
I hereby give authority for the health professional named below to release information to the
Equitable Learning Service relating to my health condition for the purposes of educational
adjustments for study.
Signature: Date:
Section B: Completed by Health Practitioner/ Health Care Provider
Practitioner / Provider Name:
Provider Stamp
Contact Details:
Diagnosis:
Nature of condition:
Permanent ☐
Temporary ☐ Expected Duration:
Condition description:
Fluctuating
☐
Stable / Unchanging
☐
Degenerative
☐
2
Impact of Condition:
Please provide information on how the student’s disability, long term illness and / or mental health
condition impact upon their study requirements. Please consider the following (as relevant to the
student’s condition): fatigue, concentration, memory, mobility, sitting / standing tolerance, impact of
medication, attendance, sensory needs; participation in activities such as presentations, lab work
and work-based learning environments.
Optional – To be completed for students who are primary carers only.
A primary carer provides the majority of the ongoing informal assistance to a person with a disability
who has a limitation in one of the core activity areas of self-care, communication or mobility.
This student is a primary carer. ☐
Please provide information on the impact of the student’s carer responsibilities on University
participation:
Any other comments?
Signature of Health Professional / Practitioner:
D
ate:
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Completed 17 August 2021

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