DISABILITY DISCLOSURE FORM

(Monitoring and Questionnaire)

For the attention of all students who have a disability and/or special needs

This form is to ensure that students with a disability and/or special needs compete fairly for study and are neither disadvantaged nor advantaged when compared with External students. Disabilities is defined as a physical or mental impairment which has a substantial and long-term (i.e. more than 12 months) adverse effect on a person’s ability to carry out normal day to day activities.

Please be assured that any information you provide on this form will be treated with sensitivity and in confidence.

Surname/Family Name: ______

First/given name(s): ______

Title: ______Student Reg. No.: ______

Date of Birth [Only required if Student Reg. No. is not known] : ___/___/___ (dd/mm/yyyy)

Subjects for which you are currently registered: ______

PLEASE ANSWER THE FOLLOWING QUESTIONS: -

  1. Do you have a disability and/or special need(s)?

Do you consider yourself to be disabled, or to have a long-term health-related condition that impacts upon your ability to carry out normal day to day activities?

Please circle as appropriateNoYes

  1. Please tick as many of the following as apply to you:

Specific learning difficulties (e.g. dyslexia)

Visually impairment

Hearing impairment

Mobility impairment/wheelchair

Physical co-ordination impairment (e.g. muscular, manual dexterity or upper limb disorder, parkinson's disease)

Autistic spectrum disorder

Speech impairment

Mental health condition

Long-term and/or chronic medical or unseen disability (e.g. diabetes, epilepsy, HIV positive)

Other, please specify: ______

  1. Do you wish to apply for special examination arrangements when you make your examination entry?

Please circle as appropriateNoYes

  1. Declaration:

You are asked to carefully read the following declarations and sign the form before you return it to the address below:

(a)I declare that the information I have provided, the statements I have made on this form, and in support of my request are, to my best knowledge and belief, true and correct.

(b)I agree to the Singapore Association of The Chartered Secretaries & Administrators processing my personal data contained in this form and other personal data that may obtain from me or from other people connected to my studies. I agree to the retention and disclosure of such data for normal academic and administrative purposes.

SIGNATURE: ______DATE: ______

WHERE TO SEND THIS FORM AND SUPPORTING DOCUMENTATION:

Please ensure you have completed all relevant questions in full and that you have read and signed the above Declarations.

If you are making a request for special examination arrangements and/or your material provided in an alternative format, you are strongly advised to make your request as soon as possible. Please be sure to enclose a letter and the medical evidence in support of your request.

This form and the supporting documentation should be sent to :

The Singapore Association of The Institute of Chartered Secretaries & Administrators (SAICSA)

149, Rochor Road, #04-06, Fu Lu Shou Complex, Singapore 188425

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