Appendix D: Note of Concern
To be completed by Head of School for each case of a student FTP self-disclosure (health) or as a record of a concern raised as to a students supports needs and/or Fitness to Practise.
Document to be retained by School. Copy to be given to student.

Student name	 		
UCC ID	 		
Address	 		

Date of Birth dd/mm/yyy    		
/	/			
Tel/Mobile    		
Programme and year study:   		
Concern raised by:   		
FTP report received	Yes		No 		
Brief outline of case:	
  Head of School name:		
Date of meeting with student dd/mm/yyyy	/	/		
If others attended this meeting please write names clearly here:	
Agreed action Plan – please tick all that apply	
	  No further action needed					
	  Student recommended to register for supports with DSS		
	Student recommended to explore supports from other UCC offices	
Other action(s):	

Next review date:	 		
Signature of Head of School  		
Date: 	

Signature of Student		
Date: 		

I understand the nature of the concern(s) raised by the university, as has been explained to me and outlined in this document and the possible impact/consequences that this/these concern(s) may have upon my own fitness to practise.

I have agreed to work towards the action plan outlined above, which has been developed to support me.

I understand that if I am unable or unwilling to carry out the action plan, the university will need to consider taking appropriate or remedial actions, or referral as my situation will require.

I understand and consent to information surrounding my fitness to practise being shared with other relevant services within the University. A copy of this action plan will therefore be submitted to the Head of School/Academic Unit and other staff as deemed appropriate by the Head of School/Academic Unit.

I am aware that this Note of Concern will be retained by the Head of School/Academic Unit. 
I understand that this case will be reviewed (insert x days/weeks or months time).

Signed:	(Student)

Signed:	(Head of School)

Dated: