Section B: Educational Impact Statement 2016

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1 Section B: Educational Impact Statement 2016 CAO Office Use Only Instructions for completion: This form has a dual purpose. It is used along with evidence of disability documentation to determine eligibility for applicants applying through DARE. The form also provides background information to colleges on the applicant s educational experience and helps to determine appropriate supports at third level. The applicant should complete the applicant statement section with support from their school. The appropriate teacher in the school should complete the school statement and the form MUST be signed and stamped by the school principal or deputy principal. A manual has been circulated to all schools to provide: guidelines on supporting applicants in completing the applicant statement guidelines on how to complete the school statement. It is the applicant s responsibility to ensure all sections of the Educational Impact Statement are completed and posted to the CAO. Remember to keep a photocopy for your personal records. Tips for Schools on how to complete the Educational Impact Statement You should save the Educational Impact Statement to your PC / laptop. Discuss with the applicant how their disability has impacted upon their educational experience. Gather all the necessary information to complete the school statement. Remember some sections will not be applicable to all applicants. When complete, print all pages and ensure it is then signed and stamped by the principal / deputy principal. Remind DARE applicants that they must return the Educational Impact Statement along with the appropriate evidence of disability to the CAO, Tower House, Eglinton Street, Galway by 1 April Applicant Details Full Name of Applicant: Date of Birth: / / CAO Number: 1 6 School Details School Name: School Address: School Phone Number: School Roll Number: Duration of School Attendance First Attended: Completion (or expected completion): 1/8

2 Applicant Statement Please describe how your disability has affected your education. (You may select as many as are applicable to you). It has impacted on my school exam results and learning. My school or class attendance has been disrupted. It has impacted on my overall experience of school. I needed and have received supports in school or exam accommodations. I need extra time with school work as a result of the impact of my disability or I need extra time to manage my condition. Please tell us how you have been impacted expanding on the above or including any other information that you think is relevant. 2/8

3 School Statement Applicant s Disability/Condition: Are there any other co-existing conditions or relevant difficulties: By proceeding to answer the questions below, the school confirms that the applicant has experienced additional educational challenges as a result of the above disability or condition in comparison with their peers. 1. Learning and Exam s 1.1 If the applicant acquired the condition when in your school (or their condition has deteriorated), has the applicant s grades noticeably and significantly decreased since the onset (or deterioration) of the condition? t Applicable If yes, please pick three subjects and in house (school) exams, pre and post onset or deterioration of a condition to highlight this. It is recommended you use Maths, English and one other subject: Subject Pre-Onset (or deterioration) please include Level and Post-Onset (or deterioration) please include Level and Please comment: 3/8

4 Please answer as many of the statements or questions below that are relevant if you have received confirmation of these from two teachers familiar with the applicant: 1.2 Applicant s ability to complete homework and study has been negatively impacted: a. Has the applicant s written work been impacted on as a result of their disability? b. Has the standard of the applicant s homework been impacted on by their disability? c. Has the applicant s ability to organise their work, meet assignment deadlines or manage their time effectively been impaired by their disability? 1.3 Applicant s performance in class or expected exam performance: a. Has the applicant s level of participation in class or concentration in class been impacted on by their disability? b. The applicant s performance in exams is not as good as expected given their level of ability shown in class 1.4 Applicant s ability to access the curriculum has been impacted: a. Has the applicant s reading been impacted on as a result of their disability? b. Has the applicant s ability to engage with the curriculum been impacted on by their disability? / Name of Teacher 1 Name of Teacher 2 / Name of Teacher 1 Name of Teacher 2 / Name of Teacher 1 Name of Teacher Please briefly describe what makes learning for the applicant more difficult in comparison to their peers? 1.6 Is the applicant attending a supported or specialised school? E.g. School for the Deaf? 4/8

5 2. Attendance and Disruption 2.1 Did the applicant s disability impact on their school attendance? Number of days missed directly attributable to the applicant s disability or condition: Number of Days Absent Number of Days Absent 1st year 4th year 2nd year 5th year 3rd year 6th year 2.2 Did the applicant s disability impact on class attendance or completion of the full school day? (Where the applicant was missing a significant amount of classes or having to leave class or school early due to the impact of disability/condition). If yes, please describe the extent to which the student missed class over their time in post primary education: Reason(s) the applicant missed a number of classes e.g. personal care needs, appointments for learning support, fatigue, condition requiring the applicant to take breaks etc. 2.3 Was there any other type of significant disruption to the applicant s post primary education? (For example the applicant had to repeat a year due to the impact of a disability). If yes, please give further details: 5/8

6 3. School Experience and Well-Being 3.1 Has the applicant s potential to participate fully in extra-curricular or social activities been constrained as a result of their condition? If yes, please provide a specific example: 3.2 Has the applicant received support due to the emotional impact of the disability/condition? t Applicable If yes, from whom: Psychologist Psychotherapist Child and Adolescent Mental Health Services (CAMHS) Guidance Counsellor Chaplain Other, please specify: 4. Intervention and Support 4.1 Has the applicant received additional support in school due to the impact of a disability? t Applicable If yes, please select years that supports were received: Support 1st 2nd 3rd 4th 5th 6th Learning Support Resource Hours Special Needs Assistant (SNA) Counselling Visiting Teacher Service Assistive Technology Care Support Team Home Tuition Hours Ed Welfare Officer Support Behavioural Support Class (NBSS) ASD Class Other (specify below) If any of the above supports indicated were not received for the entire period the applicant attended your school, please state the reason(s) for this. 6/8

7 Has the applicant been offered supports that he/she has declined? If yes, please give the reason for this: 4.2 Please confirm the exam accommodations granted to the applicant in the Junior and Leaving Cert Examination. Accommodation Junior Certificate Leaving Certificate Tape Recorder Word Processor Reader Scribe Spelling & Grammar Waiver Extra Time Special Centre Other(s) specify 5. Time Issues 5.1 The school confirms that it takes the applicant considerably longer than his/her peers to complete school work/study due to the impact of disability: If yes, please give further details of the extra time required in comparison to peers: 5.2 The school confirms that the applicant has less time than his/her peers to dedicate to study and homework due to the extra time the applicant puts into managing or living with their condition: If yes, please give details of nature & amount of time required: 7/8

8 6. Other Educational Impacts 6.1 Is there any other educational impact of the applicant s disability (or related to his/her disability) which has not been mentioned previously? If yes, please provide as much detail as possible: 7. Specific Learning Difficulty Attainment Scores 7.1 Applicants to DARE with a specific learning difficulty MUST have two literacy or two numeracy scores at or below the 10th percentile to meet this indicator. These scores are taken from the Psycho-Educational Assessment. This report must be dated after 1 February 2013 and must contain a general ability score at or above a standard score of 90. School Statement was completed by (type name): Guidance Counsellor Learning Support Teacher Visiting Teacher Head We the undersigned agree that to the best of our knowledge all the information provided on this form is true, correct and complete. Signature of Applicant Signature of Parent / Guardian (if applicant under the age of 18 on 1 February 2016) Print name of Principal / Deputy Principal: School stamp: Signature of Principal / Deputy Principal Date: 8/8

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