Medical Assessment Form Student details Student ID Name First name Last name Mobile/contact number Which recommendation is the student being assessed for? 2022/232023/24Duration of their studiesMove from current room Does the student require specialist adaptions or facilities not available in off campus accommodation? If yes please provide the details of these specific adaptions below. YesNo Is the student considered under the Equality Act (2010) to be at a substantial disadvantage compared to a non-disabled student if they were not offered a campus room? YesNo Will the student have to undergo a Fitness to Study Assessment before their return to study? YesNo Next Page Mobility Please tick all that apply Does the student have a mobility issues? YesNo Does the student have a long term and substantial impairment meaning they are unable to walk or have considerable difficulty in walking a distance more than 100 metres? YesNo Carers room EssentialHelpfulNot Required If essential, how many carers are required? Does the student require a hoist in the room/bathroom? YesNo Location Please tick all that apply Specific Hall Requested: YesNo If 'Yes' please specify hall name: Halls located close to specific area EssentialHelpfulNot required En suite room EssentialHelpfulNot Required Ground Floor EssentialHelpfulNot Required Doors and lifts Please tick all that apply Electronic lock access EssentialHelpfulNot Required Power assisted extenal doors - including building access EssentialHelpfulNot Required Power assisted internal doors EssentialHelpfulNot Required Lift access (if not ground floor) EssentialHelpfulNot Required Can the student use the stairs in case of emergency? YesNo Room Please tick all that apply Emergency call button/cord EssentialHelpfulNot Required Grab rails EssentialHelpfulNot Required Electronic windows EssentialHelpfulNot Required Laminate flooring EssentialHelpfulNot Required If you have selected essential above please provide details Previous PageNext Page Bathroom Please tick all that apply Wet room shower EssentialHelpfulNot Required Bath EssentialHelpfulNot required Grab rails EssentialHelpfulNot Required Shower chair EssentialHelpfulNot Required Easy push levers EssentialHelpfulNot Required Emergency call button/cord EssentialHelpfulNot Required Closimat toilet EssentialHelpfulNot Required If you have selected essential above please provide details Kitchen Please tick all that apply Lowered height work surfaces EssentialHelpfulNot Required Easy push leavers EssentialHelpfulNot Required Non twist sink taps Hearing issues Please tick all that apply Does the student have hearing issues? YesNo Visual alarms/flashing beacon EssentialHelpfulNot Required If essential - required in: BedroomBathroomKitchen Vibrating pillow EssentialHelpfulNot Required Visual Impairment Please tick all that apply Does the student have a visual impairment? YesNo Please give details of the students condition and any other information relevant to their room allocation on campus. Please provide as much information as possible as this will help us in selecting the most appropriate room for the student. If essential, please provide details Previous PageNext Page Please provide the name of the staff member completing this form Staff member email address Previous Page Submit