/ Medical information form for Access Arrangement applications

This form can be used by student’s applying for access arrangements in order to help them to collect evidence to support their application.

This form should be submitted with the student’s access arrangement form to:

Access Arrangements –Education Services Team, The Institute and Faculty of Actuaries, 1st Floor, Park Central, 40/41 Park End Street, Oxford, OX1 1JD, UK

Tel: +44 (0)1865 268207; Email:

Pleasecomplete thisformwithinformationaboutthe namedstudent’sdisability,medicalormentalhealth condition(s),in orderfortheIFoAto putthe appropriatereasonable adjustmentsand support inplace.
PLEASESEEPAGE3 FORGUIDANCENOTES.
FullNameofStudent / DateofBirth (dd/mm/yyyy)
Thisstudenthasthefollowingcondition(s):
Thediagnosisdatesfrom:
Whatisthelikelydurationofthecondition(s)?i.e.isthisatemporaryorpermanentcondition
Howstableisthecondition(s)?i.e.isthisastaticorfluctuatingcondition
Detailsoftheseverityandcomplexityofthecondition(s):
Howdoesthecondition(s)affectday-to-dayactivities?
Howmightthecondition(s)affectacademictasks,includingformalexams?
Medication(s)-pleasegivedetailsofanyprescribed medicationandtheimpactofanypossiblesideeffects:
Medication(s)-pleaseindicatehowtheconditionmightimpactupondailyandacademiclifeifmedicationwasnotinuse:
Overviewofcopingstrategiesusedtomanagethecondition(s):
Recommendation(s) – please indicate what you would recommend as adjustments to the exam
Signature: / Name: / Date:
In whatcapacityareyousigningthisform?(e.g.G.P. / Consultant):

Pleasevalidatethisformwithyourofficialstamporstateyourtitle,name,address,telephonenumber emailaddressincaseof aquery.

Guidance Notes

Details about the condition:

  • When providing a diagnosis, please also indicate the severity and complexity of the condition. A diagnosis alone may not be enough to help the IFoA to put appropriate support in place. For example, a statement of a diagnosis of ‘Multiple sclerosis’ does not indicate the severity or complexity of the condition as experienced by the student.
  • Please indicate how long the student has had the condition or the symptoms related to the condition and whether the condition is temporary or permanent
  • Please indicate if the condition is stable in nature or if it is likely to fluctuate.

Medication:

  • Please indicate the possible impact any medication prescribed to the student may have upon the ability to undertake examinations, for example some medication can make students feel drowsy and sluggish first thing in the morning.

Recommendation(s):

  • Please indicate what adjustments to the examination(s) you would recommend. For example, a percentage of extra time.