STUDENT DISABILITY DECLARATION FORM             

 This form is designed to elicit student disability/impairment information so that the University may make all possible provisions to help facilitate the teaching and learning requirement. All information provided here will be treated as Confidential as per the University Confidentiality policy and Disability Equality Policy. It will however, with your consent, be made available only to those staff who are directly involved in providing you with the services and that include your Counselor, the Branch Health Care in charge and your Tutor. In case of an emergency, the person authorized by you (family /doctor/caregiver) may also be contacted by AOU.

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1.STUDENT PERSONAL INFORMATION

Branch

 *

Name

 *
Student ID *
Telephone number *
E-Mail address *
Academic year *
Academic Program *
Academic semester *
Faculty Name *
Visually Impaired *
Hearing Impaired
 *
Speech Impaired
 *

Long standing illness or health condition (including Heart Disease, cancer, HIV, Epilepsy. etc)

 *

Social communication impairment as Asperger’s, Autism spectrum disorder 

 *
Learning Disability 
 *
Mental Health Condition
 *
Physical Impairment (impaired mobility) 
 *
Medical Condition not listed above
 *

3. ACCOMMODATION/SUPPORT REQUIRED (PLEASE TICK)

 *
Required
4. DETAILS OF THE AUTHORIZED PERSON
Name of the authorized person
 *
Relationship
 *
Phone Number
 *

5. If you have any other information that you feel may be relevant to us in providing you with the necessary support. Please do furnish the same here.

 *

In order to support you with your requirements, please provide evidence of your disability, physical health, or mental health related issue. We require original copies of your evidence, and where necessary, an additional verified translation.

 

I hereby consent to disclosing my disability status to those directly involved in providing me with the services and hereby I declare that all information provided here is true to my best knowledge.

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Required
Signature: ………………………………………………………………..
 *
Date: …………………………………………………………………….
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