Intercalation & Support Agreement
Faculties of Arts & Sciences, Education and Health
Student/Trainee Name:
Student Registration Number: / Date of Birth:
Contact Address:
Contact Tel No: / Email Address:
Title of Programme/Award Attending:
Faculty: *FAS/*EDUC/*HEALTH
(*delete as appropriate) / Year of Programme/Cohort:
I wish to intercalate with effect from:
(please state last date of attendance)
Intercalation policy guidelines state‘Students may not intercalate later than one calendar month before the end of teaching’
I wish to resume my studies on:
(please specify anticipated date of return)
Intercalation policy guidelines state ‘Intercalation is not an opportunity to repeat periods of study or assessment already undertaken’
I wish to return onto a different programme:
(please specify new programme)
Authorisation must be obtained from the new Head of Department / Programme Leader.
Reason for intercalation:
(if the reason is of a medical nature, a medical certificate must be attached to this form when returned)
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Moduleswhich must be completed prior to returning*:

Module No. / Semester / Title / Date

Modules which must be completed after returning*:

Module No. / Semester / Title

* Includes practice, assessment, coursework & school placement.

Student Support Agreement with Personal Tutor or Named Contact:

Personal Tutor or Named Contact:
Agreed channel of communication to be used:
*Telephone / *Letter/ *EH Email/ *Personal Email/ *Other please specify:
(*delete as appropriate / Frequency of contact agreed:
(must be at least every3 months)
Miscellaneous details:

Student/Trainee Declaration:

I confirm that the information on this form and any supporting evidence is true and accurate. I also understand that if my request to intercalate is for medical reasons I will be required to provide medical evidence to confirm that I am fit, prior to being allowed to resume my studies and to declare any criminal convictions received since my original application. Students/Trainees registered for the award of QTS or a Health Profession must complete an enhanced CRB clearance procedure prior to their return.
Signed: / Date:

Authorisation for Intercalation:

I confirm that I have discussed fully with the Student/Trainee, any areas where he/she may experience problems when they return to study on the agreed return date with particular concern to programme and module content and assessment (including assessment issues related to any referral/deferralrequirements). I have read and understood the Intercalation Notes for Guidance and confirm that the Student/Trainee is at an appropriate point within the programme to intercalate.
Personal Tutor: / Subject/Specialism/Pathway or Cohort Manager/
Leader:
Authorisation of Programme Leader/Year Leader Co-ordinator (FAS & EDUC only):
Head of Primary & EYE/Secondary (EDUC only):
Associate Dean (EDUC only):

IMPORTANT: Students/Trainees are responsible for the following:

  1. Seeking approval from the relevant members of staff on this form for intercalation.
  2. Seeking confirmation from Student Finance or Student Grants Unit if appropriate, concerning the suspension of fees and maintenance grant.
  3. Seeking advice from tutors concerning possible changes to the syllabus in the following academic year and any work, which should be completed prior to resuming studies.
  4. To remain in contact with the University during the period of intercalation as noted in the Student Support Agreement.
  5. Students/Trainees who have been granted a period of intercalation due to medical reasons must provide a medical certificate to confirm that they are in a fit state of health, prior to being allowed to resume the programme. Students/Trainees registered on a programme of study for the award of QTS or a Health Professional will also be required to complete a Declaration of Health questionnaire.
  6. Students/Trainees will be required to havesatisfied requirements set by Tutors/Examiners prior to resuming the programmeof study.

Completed forms for Faculty of Arts & Sciences and Education programmes must be returned to Academic Registry, SIC.

For Faculty of Health programmes forms are to be returned to your Personal Tutor.


Data Support …………..Tuition Fees ………….. £ Assess & Awards …………..

Snr Records Officer…………..Corres to student file ………….. CoC …………..