Isle of Wight Council

REQUEST FOR INITIATION OF STATUTORY ASSESSMENT INFORMATION FROM PARENT (S) / GUARDIAN (S)

	SECTION A
	Child

*	Surname
	Other names
*	Home Address
	Date of Birth
*	School
	Sex	Male Female
	Religion
	Home Language

Child's parent or person responsible

*	Surname
	Other Names
*	Home address
*	Telephone No
	Relationship to child

	SECTION B
	Your concerns

	What concerns do you have about your child?
	When did you first become concerned?

	SECTION C
	Help for your child

	What help has already been provided for your child and by whom? Please include any comments on how you have been trying to help?
	What progress do you feel has been made?
	What do you think will help your child in the future?

Thank you for completing this form. Please return to the SEN Section, Directorate of Education, County Hall, Newport, Isle of Wight, PO30 1UD Signed:................................................................ Date:...................................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013