1. Do you find difficulty in telling left from right?YesNo
2. Is map reading or finding your way to a strange place confusing?YesNo
3. Do you dislike reading aloud?YesNo
4. Do you take longer than you should to read a page of a book?YesNo
5. Do you find it difficult to remember the sense of what you have read?YesNo
6. Do you dislike reading long books?YesNo
7. Is your spelling poor?YesNo
8. Is your writing difficult to read?YesNo
9. Do you get confused if you have to speak in public?YesNo
10. Do you find it difficult to take messages on the phone and pass them on correctly?YesNo
11. When you have to say a long word, do you sometimes find it difficult to get all the
sounds in the right order?YesNo
12. Do you find it difficult to do sums in your head without using your fingers or paper?YesNo
13. When using the telephone, do you tend to get the numbers mixed up when you dial?YesNo
14. Do you find it difficult to say the months of the year forwards in a fluent matter?YesNo
15. Do you find it difficult to say the months of the year backwards?YesNo
16. Do you mix up dates and times and miss appointments?YesNo
17. When writing cheques do you frequently find yourself making mistakes?YesNo
18. Do you find forms difficult and confusing?YesNo
19. Do you mix up bus numbers like 95 and 59?YesNo
20. Do you find it hard to learn your multiplication tables at school?YesNo
To help us provide whatever support you need to complete your learning program, some background information would be useful. We would be grateful if you would answer the questions below. Please note that the information we want is needed so we can offer you the best possible support and not to decide whether we take you on.
1. How would you describe your record of attendance at school?
Up to 70%70/80%Higher than that
2. Did you have any gaps in your time at school? If so, how long and for what reason?
3. Were you ever suspended/excluded from school?
Did you enjoy your time at school?
5. Do you live:With your parent(s) Independently in your own accommodation:
6. Do you find communicating with other people:
EasyDifficultIt depends who they are
7. Which do you find the easiest way to learn?
In a groupOne to one with a tutorReading books and notesBeing shown and then doing it yourself
8. Are there any external agencies you are currently involved with?
9. Why do you wish to join and what do you aim to get out of this course?
10. Do you have any medical problems? Are you currently on any medication?
11. Are you registered with Connexions?
12. Do you smoke?
How We Use Your Personal Information
This privacy notice is issued by the Education and Skills Funding Agency (ESFA), on behalf of the
Secretary of State for the Department of Education (DfE). It is to inform learners how their personal
information will be used by the DfE, the ESFA (an executive agency of the DfE) and any successor
bodies to these organisations. For the purposes of relevant data protection legislation, the DfE is the
data controller for personal data processed by the ESFA.
Your personal information is used by the DfE to exercise its functions and to meet its statutory
responsibilities, including under the Apprenticeships, Skills, Children and Learning Act 2009 and to
create and maintain a unique learner number (ULN) and a personal learning record (PLR). Your
information will be securely destroyed after it is no longer required for these purposes.
Your information may be shared with third parties for education, training, employment and well-being
related purposes, including for research. This will only take place where the law allows it and the
sharing is in compliance with data protection legislation.
The English European Social Fund (ESF) Managing Authority (or agents acting on its behalf) may
contact you in order for them to carry out research and evaluation to inform the effectiveness of
You can agree to be contacted for other purposes by ticking any of the following boxes:
About courses or learning opportunities.For surveys and research.By post.By phone.By e-mail.
Further information about use of and access to your personal data, details of organisations with whom
we regularly share data, information about how long we retain your data, and how to change your
consent to being contacted, please visit:www.gov.uk/government/publications/esfa-privacy-notice
If you do not agree to share your personal information we cannot process your Application or offer
you a training place.
I have read the privacy notice
I agree for my information to be shared with the organisations mentioned above
I disagree for my information to be shared with the organisations mentioned above
If I do not agree I have also read the full implications of not sharing my data.
I have brought in my form of identification of proof of who I am.
I have seen the identification brought in by the learner
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