Section C Evidence of Disability Form 2015

Section C
Evidence of Disability Form 2015
CAO OFFICE USE ONLY:
Distributed by the CAO on behalf of
Higher Education Institutions (HEIs)
Instructions for completing this form:
This form has a dual purpose. Some Higher Education Institutions (HEIs) operate
individual supplementary admissions routes for students with disabilities. This form is used
by HEIs to provide verification of the applicant’s disability and helps to determine
appropriate supports at third level.
A number of colleges and universities operate a joint supplementary admissions route
known as DARE. This form is also used by DARE to help assess an applicant’s eligibility
for DARE. DARE requires an applicant to submit evidence of disability as part of his/her
application. An applicant’s evidence of disability documentation is used by DARE to
establish whether or not he/she meets DARE’s eligibility criteria. In addition it is used by
DARE colleges and universities to determine the kinds of supports an applicant might
need in college. An application will not be complete until an applicant provides evidence of
his/her disability on 1 April 2015. More information on DARE is available from
www.accesscollege.ie/dare.
Steps to completing this form when applying to DARE:
The table below provides a guide to submitting evidence of your disability.
Applicants who are unsure about the evidence that they need to supply can contact
any member of the DARE team. Contact details for DARE are listed in the DARE
Application Guide and on www.accesscollege.ie/dare.
Applicants who are submitting the Section C Evidence of Disability Form 2015
should make sure:
•
it is has been completed and signed by the appropriate professional AND
•
it contains the stamp of the appropriate professional or is on headed paper or
is accompanied by a business card AND
•
the appropriate professional has filled in all parts of the form AND
•
the form is legible.
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Remember
•
The online Supplementary Information Form must also be completed and
ticked for DARE where an applicant is applying for DARE.
•
Evidence completed by a GP or support organisation is not accepted as
verification of a disability.
•
Send the original Evidence of Disability form by post. Faxed/emailed
documents are not accepted.
•
Keep a photocopy of Evidence of Disability documentation for your personal
records and don’t forget to retain proof of postage.
DARE applicants must send the Evidence of Disability to:
CAO, Tower House, Eglinton Street, Galway by 17:15 by 1 April
2015.
Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Autistic
Evidence of
Consultant Psychiatrist
Spectrum
Disability Form
OR
Disorder
2015
Psychologist
(including
OR
OR
Asperger’s
Existing report.
Neurologist
Syndrome).
No age limit.
OR
Paediatrician.
Attention Deficit
Evidence of
Consultant Psychiatrist
Must be less
Disorder (ADD) /
Disability Form
OR
than three
Attention Deficit
2015
Psychologist
years old i.e.
Hyperactivity
OR
OR
dated after 1
Disorder (ADHD).
Existing report.
Neurologist OR
February 2012.
Paediatrician.
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Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Blind/Vision
Evidence of
Ophthalmologist
Impaired.
Disability Form
OR
2015
Ophthalmic Surgeon.
No age limit.
OR
Existing report.
Deaf / Hard of
Evidence of
(A) Applicants who
Hearing: Students
Disability Form
have an audiogram:
may apply
2015
Diagnostic/Clinical
under one of the
OR
Audiologist registered
following
Existing report.
with the Irish Academy of
categories:
(DARE does
Audiologists (IAA)
not accept
(B) Applicants who
who have an
reports from
attend a School for the
Audiogram
high street
Deaf: Principal of School
retailers).
for the Deaf
(A) Applicants
(B) Applicants who
attend a School
(C) Applicants with a
for the Deaf
Cochlear Implant:
(C) Applicants
Ear, Nose & Throat
with a
(ENT) Consultant
Cochlear
OR
Implant.
Cochlear Implant
Programme Co-ordinator.
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No age limit.
Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Developmental
Full psycho-
Psychologist
Psychologist’s
Co-ordination
educational
AND
Report must
Disorder (DCD) -
assessment
Dyspraxia/
AND
Dysgraphia.
Evidence of
be less than
Occupational Therapist
three years old
OR
i.e. dated after
Neurologist.
1 February 2012.
Disability Form
2015
No age limit
OR
Occupational
Existing report.
Therapist’s or
Neurologist’s
report.
Mental Health
Evidence of
Consultant Psychiatrist
Must be less
Condition.
Disability Form
on Specialist Register.
than three
2015
We will consider your
years old i.e.
OR
application for DARE
dated after 1
Existing report.
once we receive a
February 2012.
diagnosis of a significant
and enduring mental
health condition which
impacts on daily function.
Neurological
Evidence of
Neurological
Conditions
Disability Form
Conditions: Neurologist
(including Epilepsy, 2015
OR
Brain Injury).
OR
Other relevant
Existing report.
Consultant.
Speech & Language
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No age limit.
Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Disabilities: Speech and
Language Therapist.
Neurological
Evidence of
Speech & Language
Conditions
Disability Form
Disabilities: Speech and
(including Speech
2015
Language Therapist.
and Language
OR
Disabilities).
Existing report.
Physical Disability.
Evidence of
Orthopaedic Consultant
Disability Form
OR
2015
Other relevant
OR
consultant appropriate
Existing report.
to the
disability/condition.
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No age limit.
No age limit.
Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Significant On-
Evidence of
Diabetes Type 1:
Must be less
going Illness.
Disability Form
Endocrinologist
than three
2015
OR
years old i.e.
OR
Paediatrician.
dated after
Existing report.
Cystic Fibrosis (CF):
Consultant Respiratory
Physician OR
Paediatrician.
Gastroenterology
Conditions:
Gastroenterologist.
Other Conditions:
Relevant Consultant/
Specialist in area of
condition.
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1 February
2012.
Type of
Type of
Appropriate
Required
Disabilit
Documentation
Professional
Age of
y
Report
Specific
Full psycho-
Psychologist.
Must be less
Learning
educational
than three
Difficulty
assessment.
years old
(including
i.e. dated after
Dyslexia &
1 February
Dyscalculia).
2012.
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Please complete all sections below in TYPE or BLOCK capitals:
1. Applicant Details
Title and Full Name of
Applicant
Date of Birth
CAO Number
2. Medical Consultant/Specialist
Name and Title of
Consultant/Specialist
Phone
(including area codes)
Position / Professional
Credentials
Date of Report
Date of diagnosis / onset of
disability
3. Disability Information
Disability Type (please tick primary disability):
Autistic Spectrum Disorder
Mental Health Conditions
(including Asperger’s Syndrome)
ADD / ADHD
Neurological Conditions (including Brain
Blind / Vision Impaired
Injury, Speech and Language
Deaf / Hard of Hearing
DCD–Dyspraxia/Dysgraphia
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Disabilities)
Physical Disabilities
Significant Ongoing Illness
Specific Learning Difficulties
(including Dyslexia & Dyscalculia)
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Please state the specific name of the disability (if relevant):
Please state if there are any other disabilities
4. Outline the history and detail of the disability. Confirm if the condition is
congenital or acquired; and if it is permanent, temporary or fluctuating.
5.
Will the condition remain static, have periods of relapse/remission or is
it progressive?
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6. Describe measures currently being taken to treat the disability (e.g.
medication, therapy etc.)
7. If the applicant is Blind / Vision Impaired, state the visual acuity scores,
field of vision loss, loss of near vision, central vision or peripheral
vision where appropriate.
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8. How does the disability / medical condition impact on the applicant’s
ability to study and participate in school / college (e.g. impact on school
attendance, ability to engage with the curriculum, examination
performance etc.)?
9. What recommendations would you make for reasonable
accommodations / supports to enable equal participation in Higher
Education (e.g. adaptive equipment, examination accommodations
etc.)?
Official Stamp: This form must
be completed and signed by
the appropriate professional. In
addition it should be stamped
or accompanied by a business
card or headed paper.
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Consultant’s signature
___________________________ Date____ /
____ / ____
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