Transfer and Refund Policy
adult learning and skills service
Additional Support Referral Form
Many learners who need additional support because of a language,
literacy or numeracy need, learning difficulty or disability can be
helped by the lecturer within the class. Please use this form to
refer any learner you believe would benefit from any additional
support. You should discuss this referral with the learner
concerned and inform them that a member of staff will contact them
to arrange a confidential interview. A member of staff will assess
the learner's support needs, make arrangements for support to be
put in place and confirm the support to be provided. The completed
form should be handed in to Reception or emailed to
[email protected] .
If you would like to discuss a possible referral, or get advice
about how best to work with a learner with any of these needs,
please contact the relevant member of staff.
Learner Name Enrolment Number .
Course Title Course Code ....
Please tick reason support needed and give a brief description
of support needs[ ] Spoken English [ ] Literacy [ ] Numeracy[ ]
Learning difficulty
[ ] Physical disability [ ] Hearing impairment
[ ] Visual Impairment
[ ] Other support needs (please specify)
Recommended Form of Support
[ ] Support in class
[ ] Additional support out of class
[ ] IAG interviewDetails of Referral
If you are recommending the learner needs out of class support
please give the SMART learning aim that you want the learner to
achieve
.......
If you are referring to an IAG interview please give any
relevant details on what the learners enquiry is regarding ...
.......
Other relevant information/comments:
Signed (Lecturer) ..Date
Note to Reception Staff:
Please fax or email this form to Lee Brown immediately and send
the original to Sean Buckley via the internal post in a sealed
envelope marked CONFIDENTIAL.CONFIDENTIAL
CSD/ALSS/SB/REFERRAL FORM JUNE 2011/YSP/21.06.11
