Self-assessment form accommodation
Please complete this form to advise the universitys Accommodation Services of
any diagnosed medical or mental health circumstances which have a severe/long
term impact on your day-to-day activities, mobility or sensory perception. Please
be sure to indicate the relevance of any conditions in terms of your
accommodation requirements.
Student details
Full name
Student ID number
Campus of study
Course and year
Current address
Mobile number
Email address
Self-assessment
Diagnosis / disability
Please identify any current diagnosed medical or mental health conditions and give
details as to how they are relevant to your residential requirements. Include details of
any medication and ongoing treatment you are receiving. Please give as much detail as
possible and indicate why your disability / condition inhibits you from taking alternative
private sector accommodation.
Please note: you must have diagnostic evidence of your disability / condition.
Severity of disability / condition: e.g. acute, chronic, temporary, progressive
Effect on daily life (please tick):
Some Regular Significant Major
I have discussed my diagnosis with Roehampton Disability Services Yes
No
Additional details
Please check any of the following that are applicable, with details:
Reasoning please give full details
Will you require a carer while Yes
in residence? No
Is there any special Yes
equipment that you are No
required to use on a day to
day basis, and will you be
bringing this with you?
Is there any requirement for Yes
additional equipment to be No
provided by the university
(subject to assessment)?
Will you require:
En-suite bathroom Yes
No
Ground floor room Yes
No
Wheelchair access Yes
No
Lift in residence Yes
No
Own refrigerator Yes
No
Adapted accommodation (eg Yes
handrails, , deaf alerter, fire No
evacuation aids)
Will you require a Personal Emergency Evacuation Plan (PEEP)?
A PEEP is an agreed action plan that provides people, who may not be able to exit the building unaided, with the
necessary information about emergency evacuations. It also allows us to know what level of assistance you may require.
It doesnt involve unnecessary disclosure of confidential medical information; it is just an agreement about what
procedures to follow. Not every person with a condition will need a PEEP, but all building users should be sure they know
what to do in an emergency evacuation of the building. Yes No
Other (please give details):
If something which concerns you is not listed, please contact Accommodation or
Disability Services for advice.
Professional Assessment
THIS SECTION IS TO BE COMPLETED BY THE APPLICANTS MEDICAL
PRACTITIONER GP / Doctor / Occupational Therapist / Specialist / Consultant
Details
Full name
Name of
applicant /
student
Relationship to
applicant / Job
title
Business address
Telephone
number
Email address
Mobile number
Email address
Professional diagnosis
Details of disability or condition
The effect of the above on applicants day to day housing requirements
Details of medication and / or ongoing treatment
Please note:
- Partially completed forms cannot be processed
- Forms returned without a professional assessment cannot be processed
- Completion of this form does not guarantee the allocation of halls of halls of
residence accommodation this will be dependent on availability and the
decision of the panel
- In some circumstances a site visit may be required to assess suitability
- You may be required to provide additional evidence to support your
application and / or attend a consultation.
- If accommodation is agreed for you, you will be required to submit an
application on the basis of disability yearly.
Declaration
I confirm that the information given is true and correct.
I understand and consent to the sharing of information relating to my disability /
medical condition for the purposes of assessing my housing needs while at the
University of Roehampton.
Signed___________________________________________ Date
_________________________
Please return these forms to:
Disability Services
Student Experience
Richardson Building, Digby Stuart campus
University of Roehampton
Roehampton Lane| London | SW15 5PU
disabilities@[Link]
Tel: +44 (0) 20 8392 3636
Please note: you must submit a self assessment form for each year that
you are applying for accommodation on the basis of a disability related
need.
