PSO 2855 - Inside Time

PSO 2855 Page 14ANNEX BDISABILITY QUESTIONNAIRENB: Some prisoners who have a sight or hearing impairment or have difficulty in understandingmay need help to complete this form. Or it can be printed out in a larger font.Please note: It will be necessary to share relevant information with staff includinghealthcare, to verify the level of your disability and ensure that any reasonable adjustmentthat you may need can be put in place. However, this will only be to the extent necessary,and otherwise the information will be treated as confidential.NAMEPRISON NUMBER1. Do you agree to provide the Prison Service with information about any disabilitiesyou have and your needs?YES/NOIf no, please go to 4 below and sign the form.2. What obstacles do you face in day to day activities?3. What facilities, or other support, do you need to carry out normal day to dayactivities? (e.g. British sign language interpreter, large print books, amplified telephones,special eating utensils etc.)Issue No. 295 Issue date 3/04/08