Disability Services
Health Practitioner Report
Please return this form to Student Life and Learning reception,
email to [email protected], or bring to your
appointment with a disability adviser.
The University provides support services and reasonable academic
accommodation for students with a disability, injury or health condition. The
aim is to reduce the impact of these conditions on the student’s study.
To assist the University in determining the most appropriate support for this
student, your assessment of their needs is required.
Authority to release information
I,……………………………….……. give authority for …………………………………..
(Student Name)
To release information relating to my disability or health condition to the
Disability Service at the University of the Sunshine Coast.
Disclosure of information is voluntary. The information you provide is treated
as private and confidential. No information is released without your written
consent, except where required or authorised by law, for example if the staff
member believes that you or others may be at risk.
Signed:……………………………………………..…………
Date:…………………
Practitioner to complete this section or attach relevant
documentation
Name:…………………………………….…………………..
Date:……………………..
Profession:………………………..…………………………..
Signature:……………………………………….………..…..
Phone:..……………………………………………………….
Clinic Stamp
Email:…………………………………..................................
Student Life and Learning, University of the Sunshine Coast, QUEENSLAND,
AUSTRALIA Tel: 07 5430 1226 | Email: [email protected] | Web:
www.usc.edu.au CRICOS Provider Number: 01595D
To be completed by practitioner
Information relating to disability
Diagnosis: ……………………………………………………………………………………
Date of diagnosis:…………………………………………………………………………..
Further relevant details (e.g. temporary / ongoing, condition to be reviewed, risk
factors, management information, medication):…………………………………….
………………………………………………………………………………………………….
Functional implications on student’s study
1. Please describe how this condition could affect the student’s functioning in an academic
setting, based on your assessment, e.g. reading, writing, cognitive skills, mobility, attendance,
access.
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
2. Please indicate if any specific adaptive equipment / software / furniture has been prescribed
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
Recommended strategies to assist the student:
☐Access to Respite Room – student does not require medical supervision
☐Extra time during exams ☐Flexible exam scheduling
☐Use of a computer / software for exams
☐Others:
Details:
………………………………………………………………………………………….
……………………………………………………………………………………………….….
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
Student Life and Learning, University of the Sunshine Coast, QUEENSLAND,
AUSTRALIA Tel: 07 5430 1226 | Email: [email protected] | Web:
www.usc.edu.au CRICOS Provider Number: 01595D