Reasonable Adjustment Application Form Personal details First Name(s) Last Name College Reference Number (CRN) GMC Number Email address Please select the exam you intend to sit -Select-Final MCQFinal OSCE & SOEFinal OSCEFinal SOE Please tell us the date of the exam you are intending to book. You must ensure you book the exam by the stated deadline. Remember to check the box for adjustments on the online booking form. Tell us more about your reasonable adjustment request Have you had reasonable adjustments in a previous sitting of a FFICM exam? Yes No Please select the exam where you had your previous reasonable adjustment -Select-Final MCQFinal OSCE & SOEFinal OSCEFinal SOE Please confirm the month and year you sat the exam Please confirm the month and year you sat the exam: Month Please confirm the month and year you sat the exam: Year Please select one of the following options I would like the same accommodations I have had previously This is a new request for reasonable adjustments I would like the same accommodations I have had previously with new requests What is the reason you are requesting reasonable adjustments? Please detail the disabilities and/or health conditions that you are requesting reasonable adjustments for Please list below the reasonable adjustments you would like to request for the exam. List each reasonable adjustment you are requesting. Supporting evidence is needed for each request Reasonable adjustment supporting evidence Do you have supporting evidence for each of the reasonable adjustments requested? Supporting evidence options Yes No – I am waiting for my supporting evidence but will be able to email it No – I do not have supporting evidence Other Please confirm the date you will be able to forward this to us below Please upload your evidence below One file only.256 MB limit.Allowed types: rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Reasonable adjustments granted in the workplace – it is helpful for us to know what reasonable adjustments have been put into place at your workplace, please provide as much information as you feel is relevant to your request Consent and confidentiality It is possible that we may need to obtain further information regarding your disability before being able to decide whether reasonable adjustments can be made. We would therefore like your consent to contact: Your educational supervisor – if we need to obtain further information/confirmation of any adjustments that have been made for you in the workplace. The disability assessor who provided the documentary evidence provided to support your application if further clarification is needed. You are entitled to withhold your consent however this may make it more difficult for us to determine accurately what reasonable adjustments should be made. Consent to obtain further information I consent I do not consent The information provided in this form, and any additional supporting information that you provide, will be held by the Examinations Department at the RCoA in accordance with the General Data Protection Regulation 2016 and Data Protection Act 2018 (C.12). Outside of this department, it will only be shared with the examination’s leadership team at the College and on occasion, the disability advisor at the Academy of Medical Royal Colleges if further discussion is needed. Reasonable Adjustments granted for written exams will be shared with TestReach. I confirm I have read and understood the confidentiality statement CAPTCHA Math question 6 + 9 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
