AQH-F6-13-1-2
Extenuating Circumstances Form
Version 1.0 February 2016
If you apply for extenuating circumstances and then hand in assignments or sit an exam, you therefore deem yourself ‘fit to sit’ and this application will then become void.
Student Name______Registration Number ______
Programme______Stage______Faculty/Department:______
Location of study (delete as applicable, and if partner college please give name):
Sunderland Campus
London Campus
Partner or Collaborative College please give name of college:
Subject 1 ______Major / Dual / Minor Subject 2 ______Major / Dual / Minor
All the following boxes must be completed when applying for extenuating circumstances, if more than one assessment please specify them all:
ModuleCode / Sem
1/2/3 / Module Title / Exam / Test
Dates / Coursework/
Portfolio
Dates / Placement
Dates
Summary. Please give a justification for extenuating circumstances in the box below:
Please note: Form(s) of evidence must accompany this form. Original documentation is required. If extenuating circumstances are on medical grounds, medical evidence must be attached or a letter from a counsellor. If extenuating circumstances are on other grounds, appropriate documentary evidence must be attached.
I have read the University’s Regulations on consideration of Extenuating Circumstances. I understand that if I subsequently engage in the assessments listed on this form I declare myself ‘fit to sit’ and this application will be disregarded. I declare that the information I have given on this form is accurate.
Student Name and Signature:
………………………………………………......
Submission Date:......
UNIVERSITY OF SUNDERLAND
RECEIPT OF EXTENUATING CIRCUMSTANCES FORM
Name of Student______Registration Number______
Authorised Signature ______Date Received______
More guidance available
Please see the guidance notes that accompany this form and which are available at
AQH-F6-13
Procedures for extenuating circumstances:
Hand-in arrangements
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