Special Provision Application ------- Parent Form
This form is for short term or long term special provision for school assessment. Please provide supporting documentation (reports, medical certificates) if available. Reports older than 12 months may not be valid - please contact Education Support or Student Services if you have any questions. The Student Services team will make an assessment of the application using QCAA guidelines. Applications for Year 12 QCS Special Provision must be made through the Student Services office.
Student Name *
Your answer
Date of Birth *
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Year Level *
Name of person filling in this form. *
Your answer
Contact details
Please provide an email or phone number in case we need to clarify details of the application. We will also alert you of the outcome of the application using this number/email.
Your answer
Medical Condition / Impairment / Disability/ Learning Difficulty/ Disorder *
Your answer
Disability Category (Nationally Consistent Collection of Data - School Students with Disability) *
In which broad disability category is this disability/condition?
Required
Impact of condition on teaching/learning process/assessment. *
Please provide sufficient information to enable the Student Services and Education Support team to make a clear assessment.
Your answer
Medical/Professional
Who made this diagnosis/assessment? Please provide the name of the doctor or specialist.
Your answer
Contact information
Email/Phone details of doctor/specialist.
Your answer
Date of report
MM
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DD
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YYYY
Review Date (if applicable)
Please note reviews may be required if reports are older than 12 months.
MM
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DD
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YYYY
If no current diagnosis is available please provide sufficient justification for Special Provision.
Please note that Special Provision Adjustments are allocated only when sufficient information has been presented to Student Services or Secondary Education Support. If you have any questions, please contact either office on 3353 1266.
Your answer
Recommendations for Special Provision (Reasonable Education Adjustments) *
What are the suggested special provision requirements? Please tick all that apply.
Required
Time-frame *
For which school terms will special provision be required? Please tick all applicable.
Required
Permission to disclose. *
Information you provide will inform best practice for exams and assessment as well as general classroom practice. Please confirm that you are happy for all relevant school staff to be made aware of the information you have provided.
Required
Additional comments
Please use this space to communicate any other information you feel is important for this application.
Your answer
If you cannot bring in copies of reports personally, please post or email copies to studentservices@northside.qld.edu.au
Please phone Mrs Kerry Pass through the school phone 3353 1266 to arrange a meeting with Student Services staff.
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