program for students with disabilities application summary form confidential psd identification number surname (as per cases21) f

Program for Students with Disabilities Application Summary Form
CONFIDENTIAL
PSD Identification Number
Surname (as per CASES21)
First name (as per CASES21)
Date of birth
Male
Female
Year level
Enrolment status
Time fraction
Entry Date
 / / 
Name of school submitting the application
Number of school submitting the application
Region
Educational Needs Questionnaire
Is the application for Intellectual Disability or Severe Language
Disorder with Critical Educational Needs?
YES NO
If YES, assessment completed by:
Assessments Australia
Other (specify)
 
MOBILITY
 
Safety
 
Fine motor skills
 
Hearing
 
Receptive communication
 
Vision
 
Expressive communication
 
Self-care
 
Challenging (excess) behaviour
 
Medical
 
Frequency
 
Cognitive skills
Application Checklist
The application is signed by all parties as complete and accurate
All evidence to establish eligibility and support of ENQ indicators is
attached
The completed ‘Student Learning and Support Statement (Goals and
Strategies)’ is attached
The application has been entered in PSDMS and the information is
identical in online and paper copies
Student Support Group Declaration
We declare that this application is complete and addresses all
relevant aspects of the PSD Guidelines. The appropriate procedures
have been followed and this form has been completed to the best of our
ability to accurately represent the circumstances of the student. We
have read and accepted the privacy statement attached to this form,
available at
www.education.vic.gov.au/about/programs/needs/Pages/disabilityprogram.aspx.
Date:  / / 
Parent/Guardian Name: Signature:
Principal Names: 1   Signature:
2   Signature:
Department Nominee Name:   Signature:
For office use only
Date received:  
RCG date:  
Status:
Comments:
Start date: T   / 20 
End date: T   / 20 
SL&SS:  
Application considered for category
 New
 Reappraisal
 6 - 7 Review
Fasten the completed application with one staple or clip only.
Do not bind or place in plastic pockets.
POST the application to:
Do not courier or deliver.
Resources Coordination Group
Program for Students with Disabilities
Locked bag 32005
Collins Street East, VIC 8003
Privacy and Security Notice
Schools must provide the following written statement to the
parent/guardian/carer(s) of students for whom applications have been
prepared and submitted:
The Department values the privacy of every person. The Department,
including all school staff, must comply with Victorian privacy law and
applicable privacy policies.
The collection of personal and health information by Victorian
government schools, on behalf of the Department, is governed by the
Privacy and Data Protection Act 2014 (Vic) and Health Records Act 2001
(Vic) (collectively, Victorian privacy law).
How will we use the student’s Program for Students with Disabilities
(PSD) information within the Department and student’s school?
The Department, including all Victorian government schools, is a
single legal entity. This means that:
*
the Department, through Victorian government schools, collects
health information through this PSD application process for the
primary purpose of educating and supporting students and to
fulfill various legal obligations
*
the Department’s legal obligations include its duty of care to
students, making reasonable adjustments for students with
additional needs and/or disabilities (anti-discrimination law) and
providing a safe and secure workplace (occupational health and
safety).
Consistent with its primary purpose, the Department, through its
contracted PSD evaluation service, will use the student’s PSD
information to:
*
provide detailed and balanced information on all available
educational options for the student
*
help determine the specific educational needs of the student
*
when eligibility is established - determine additional resources
to be provided to the student’s school.
If the student transfers to another Victorian government school, that
new school will have access to the information regarding the student’s
PSD eligibility and learning and support planning through the Program
for Students with Disabilities Management System (PSDMS).
Disclosure of information externally to the Department and school
The Department, including the student’s school, will not disclose the
student’s health information collected through this PSD process to an
external entity unless you have provided written consent or when
required by, or permitted under, law.
Security and retention of information
All information collected through this PSD application process is kept
secure and treated as confidential. We respect the right to privacy
and will only release information about a student with written consent
or as required by, or permitted under, law. All Department staff
handling student information must comply with Victorian privacy laws.
Accessing and sharing information
A PSD application primarily consists of medical or allied health
reports, an Application Summary Form, a Student Learning and Support
Statement (Goals and Strategies) and a covering letter from the school
principal. Typically the student’s parent/guardian/carer(s) provide
copies of the reports contained in an application and would therefore
have access to such reports at the time of making the application.
The student’s school will keep a copy of all PSD application documents
and on request, this information will usually be provided to a
student’s parent/guardian/carer(s). If a school cannot assist in
providing PSD application documents, the parent/guardian/carer(s) will
be referred to the Regional Disabilities Coordinator at the relevant
regional office for assistance. In some circumstances, due to the
volume, sensitivity or complexity of the information, or due to
potential impacts on a person’s privacy, the parent/guardian/carer(s)
may be required to make a Freedom of Information application. This
allows the Department to determine access in accordance with relevant
information legislation.
See: Regions.
If you do not provide the information required for the application,
the Department may not be able to provide the school with
supplementary PSD funding.

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