PSAC – GRADE 5 ASSESSMENT 2018 SPECIAL CONSIDERATION FORM

Section 1 - School

School Name School Code

School Address Tel No.

Section 2 - Candidate’s Details

Surname: Other name(s):

Date of Birth: / / Gender: Male Female (please as appropriate)

Phone No. Home: Mobile: NIC:

Address: Email Address of Cand./Resp. Party

Optional

subject:

Hindi Urdu Tamil Marathi Telugu M.Chinese Arabic KM Nil

Section 3 - Medical Problem

Please indicate whether Permanently/Temporarily Handicapped*

Description of medical problem:

Is medical certificate enclosed? Yes/No*

Note: Mention should be made on the Medical Certificate (from a Government Medical Officer) of the

specific requirement(s) of the candidate, e.g additional time, assistance of a Writer/Reader,

enlarged question paper, etc. Otherwise request(s) will not be entertained.

Section 4 - Special arrangements requested ( as appropriate)

1. Extra time

2. Enlarged Print Question Papers

3. Assistance of Writer

4. Assistance of Reader

5. Assistance of Sign Language Interpreter

6. To be examined in a separate room

7. To be examined on ground floor level

8. Other (please provide details)

Section 5 - Other handicaps (admission to hospital/clinic, language problems - applicable to newly settled expatriates, bereavement, etc.)

Please specify: …………………………………………………………………………………………….

…………………………………………………………………………………………….

Section 6 I certify that the information given above is true and correct.

Name: ……………………………………

Status: ……………………………………

Signature: ………………………………..

Date: …… / …… / ……

* delete as appropriate

Note: For Private Candidate, Section 1 should not be filled in.

Form SC5

Seal of School