YOUR ID NUMBER

National Student Financial Aid Scheme Disability Annexure A

DISABILITY ASSESSMENT QUESTIONNAIRE

Applicants who are currently receiving the funding for students with disabilities do not need to submit this Annexure. Should the nature of your
disability change over the term of study, and if this impacts directly on your ability to participate in your educational programme, then you will need
to submit updated details and a full medical/rehabilitation report from a certified professional. Failure to provide the information requested on all
pages will render this application incomplete.

Please complete in detail, in legible handwriting with certification and verification by a registered healthcare professional or disability support office
(where indicated). Please see notes at the end of this document for more information regarding the completion of the form. This form should
accompany your application for financial assistance if you have indicated that you have a disability. All information contained in this form will
remain with the university/university of technology and/or NSFAS only and will remain confidential.

Explanation of disability:

Washington Group Category of Disability Description Of Disability

Sensory Disability Blind No functional vision

Partially-sighted Functional vision with limitations that may be reduced through the use of
electronic or manual low-vision devices. (Vision cannot be fully corrected
through the use of prescriptive lenses)

Deaf (capital D) Little or no hearing: generally makes use of South African Sign Languages
(SASL) and typically subscribes to Deaf Culture

deaf (lower case d) Little or no hearing, do not make use of Sign language as a medium of
communication, makes use of various means of communication such as
speech, speech reading/cochlear implants or a combination of these.
Aligns with impairment/disability and the hearing world.

Hearing Impaired None, little or some hearing: generally makes use of appropriate hearing
technology e.g. Cochlear Implants, Hearing Aids, and other assistive
listening/living devices and typically uses verbal communication. Align
themselves with impairment and the hearing world.

Hard of Hearing Persons with different degrees of hearing loss, who do not align with
impairment and disability.

Deaf-Blind No functional vision and no hearing

Specific Learning / Neurodevelopmental Intellectual Disabilities

Developmental Disability Disabilities Communication Disabilities, Language and Speech Disability (e.g.
stuttering),
Autism Spectrum Disorder,
Attention Deficit/Hyperactivity Disorder (ADHD),
Specific Learning Disabilities

Psychosocial / Psychosocial Disability Such as Depression, Schizophrenia

Psychiatric Disabilities

Physical Disability Physical Disability Loss of a limb or makes use of crutches, Wheelchair User, Person with
Cerebral Palsy

Chronic Illness A long standing medical condition /illness that affects daily functioning.
Such as Chronic Heart Condition, Chronic Diabetes Cancer

Any disability not Give details Any disability not mentioned above
mentioned above

Physical Disability of a Temporary Disability: Physical Disability of a Temporary Nature

Temporary Nature disability not longer than 6
months

Email us [email protected]
You may also visit your nearest university/TVET college financial aid office for assistance.

APP2022V1
 YOUR ID NUMBER

Disability Annexure A

National Student Financial Aid Scheme

FIRST NAMES (in full, as per your ID document)

SURNAME (as per your ID document)

Disability information:
This section could be completed by a certified, professionally registered medical doctor or other appropriately qualified professional viz.
optometrist, physiotherapist, disability unit head), who can confirm the disability status of the student and state what support the student
requires and how the student would benefit from the support proposed.

Please indicate the type of disability in the section below.

See the table overleaf for information and explanation of the disabilities. (please mark with an X)

Blind deaf Deaf-Blind

Chronic Illness Deaf Hard of Hearing

Hearing Impaired Physical Disability Neurodevelopmental Disabilities

Partially-Sighted Psychosocial Disabilities Any other Disability

Please provide further details if you have a disability not mentioned above: (please give detailed explanation and provide a medical report from a
medical practitioner)

Psychosocial and neuro-developmental disability - please describe the nature of the support required (a detailed report, not older than 3 years from a
registered Psychologist or Psychiatrist will need to be provided to support this application).

Chronic Illness - please describe the nature of the support required by the student (a detailed recent medical report from a registered medical practitioner
will need to be provided to support this application explaining how the condition impacts on the teaching and learning process of the student).

Details of Practitioner: (if completed by the University/College Disability Unit (DU), this form must be completed by the Head of the Unit. The additional
medical reports required must accompany this form where appropriate)

DATE

Y Y Y Y M M D D

SIGNATURE

ORGANISATION STAMP

APP2022V1