UAC APPLICATION NUMBER: 132545319
MISS AIDA ABOUZEID
9 BRUCE ST KINGSFORD NSW
H01B: ILLNESS/DISABILITY OF AN IMMEDIATE FAMILY MEMBER OR CLOSE
FRIEND
WHAT YOU NEED TO DO
1. Complete the applicant statement of this form.
2. Arrange for the educational impact statement to be completed.
3. Collect all relevant documents outlined under ‘Documentation required’.
4. Upload this completed form and documents to your EAS application, as soon as possible.
– If you need more room to write your statement, use a separate sheet of paper.
– UAC will not contact you in relation to missing or insufficient H01B documents.
– Your application can’t be assessed until your supporting documents have been uploaded.
– Any hard copies of documents received by UAC will be scanned then destroyed.
ELIGIBILITY CRITERIA
Your home environment was severely disrupted for a period of at least six months due to the severe or life-threatening illness/disability
of an immediate family member or close friend during Year 11 and/or 12 or equivalent.
EDUCATIONAL IMPACT STATEMENT: REQUIRED FOR H01B
The Educational Impact Statement (EIS) must be completed by someone who can comment on the circumstances outlined in your
applicant statement and must not be altered, or added to, by you in any way.
If you’re a current Year 12 student: the EIS must be completed by your school/college principal, counsellor, year adviser or careers
adviser. If you’re unable to have your school complete the EIS, it must be completed by a responsible person. You must also attach an
explanation as to why your school can’t complete the EIS.
If you’re a non-Year 12 student: the EIS must be completed and signed by a responsible person.
A responsible person is a doctor, lawyer, accountant, social worker, counsellor, religious or community leader who is familiar with
your circumstances and who can provide information regarding your disadvantage and its effect on your ability to study. The person
must not be a family member or friend.
DOCUMENTATION REQUIRED
– Applicant statement
– Educational impact statement
– A medical certificate/report giving full details of the length of illness and its severity. Include information about treatment,
medication, hospitalisation.
UAC APPLICATION NUMBER: 132545319
MISS AIDA ABOUZEID
9 BRUCE ST KINGSFORD NSW
H01B: ILLNESS/DISABILITY OF AN IMMEDIATE FAMILY MEMBER OR CLOSE
FRIEND
APPLICANT STATEMENT
1. Who is the person with the illness or disability?
2. Describe the nature of your relationship to the person/s with the illness/disability.
3. Provide details of the duration of the illness/disability and the school years involved.
4. Describe the effect on your home environment, you personally and on your educational performance.
5. If you have any other information specific to this claim that may inform our assessment, please provide details.
UAC APPLICATION NUMBER: 132545319
MISS AIDA ABOUZEID
9 BRUCE ST KINGSFORD NSW
H01B: ILLNESS/DISABILITY OF AN IMMEDIATE FAMILY MEMBER OR CLOSE FRIEND
EDUCATIONAL IMPACT STATEMENT
To be completed by the school or a responsible person.
1. Have you identified an impact of the circumstances described by the applicant, on their educational performance?
Yes No
2. If yes, indicate the impact of the applicant’s circumstances on their educational performance by ticking ( ) the appropriate box.
Extreme Considerable Moderate Slight
3. What was the duration of the educational disadvantage?
Years Months
Put a dash (-) in any unused boxes
4. Please provide details of the educational impact.
Details of person completing the Educational Impact Statement
Name (print) Position/occupation
Name of organisation (if applicable)
Address State Postcode
Daytime telephone Alternative telephone
Signature Date
UAC APPLICATION NUMBER: 132545319
MISS AIDA ABOUZEID
9 BRUCE ST KINGSFORD NSW
H01B: ILLNESS/DISABILITY OF AN IMMEDIATE FAMILY MEMBER OR CLOSE
FRIEND
DECLARATION – PROVISION OF THIRD PARTY HEALTH INFORMATION
If you are providing health information about someone other than yourself, you should obtain that person’s consent where possible by
requesting they complete, sign and date declaration a). If you are unable to obtain that person’s consent in writing, due to illness or
extenuating circumstances, provide an explanation, sign and date declaration b).
Declaration a)
I give consent for to
supply health information about me in this Educational Access Schemes application. I understand that I can access my health
information by writing to UAC.
Third party’s signature Date
Declaration b)
After having taken reasonable steps to obtain third party consent in order to provide health information about that person, I was unable
to because:
Applicant’s signature Date
