FORM DBE 124
ANNEXURE B
Application by the SBST/DBST for an Accommodation, Concession, Exemption or
Endorsed NSC to alleviate the learning barrier(s) experienced by the learner
SCHOOL: ,……………………………………………………………………………………………………………………
LEARNER: ,…………………………………………………………GRADE: ,…………………………………………
Attach a copy of the Learner Profile and SNA 1 – 3 as background information when applying to the relevant district/
provincial structure. Please follow your provincial guidelines in terms of extra information and documentation needed.
LIST OF ACCOMMODATION(S)/EXEMPTION(S) YOU ARE APPLYING FOR:
(Mark your choice with an X)
SUBJECTS
TYPE OF ACCOMMODATION REQUESTED
Adaptation of questions
Additional Time
Digital Player/Recorder
Braille
Computer/voice to text/text to voice
Enlarged print
Handwriting
Medication/food intake
Oral examination
Personal assistant
Prompter
Reader
Rest breaks
Scribe
Separate venue
Sign language interpreter
Spelling
Transcription of Braille
Video/DVD recorder/Webcam
Endorsed NSC
Exemption from a language
Language: …………………………………
(immigrant/refugee learner with a study permit)
Comments
SURNAME, INITIALS
VERIFIED AND SUPPORTED SIGNATURE DATE
(PRINT)
Parent/Legal Caregiver 20.... / .... / ....
Learner (if applicable) 20.... / .... / ....
SBST coordinator 20.... / .... / ....
Principal 20.... / .... / ....
DBST coordinator 20.... / .... / ....
APPROVAL:
District Office Official 20.... / .... / ....
Provincial Official (for Grade 12) 20.... / .... / ....
CONFIDENTIAL 1
