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Emergency Temporary Exam Support Request Form
2015/16 Semester 2 Examinations
Student Name / Student No /
Telephone No / UCD Connect Email address (all correspondence will be sent to your UCD Connect account)
Exam Module Codes
EMERGENCY TEMPORARY SUPPORT REQUEST
  • The closing date for receipt of temporary support request forms and accompanying documentation for the end of Semester 2 2015/16 examinations is 12.00 noon on Friday, 29 April 2016. Emergency requests may be considered after this date with appropriate medical documentation.
  • Please note that Assessment, UCD Registry will make every reasonable attempt to accommodate a student’s request for temporary supports for end of semester examinations.
  • Temporary support is based on recent medical documentation only. Current and relevant medical information must be inputted in the section below (see list of accepted medical professionals below).
  • If you have a diagnosed disability, significant on-going illness, Specific Learning Difficulty or mental health condition, you should email and request an appointment to discuss supports. Specific documentation of a disability is required in order to provide students with Reasonable Accommodations. Please see Supports for Students with a Disabilityfor full details.
  • This form will be retained for a period of 13 months after which time it will be destroyed.
  • Students with an infectious illness cannot be accommodated in the Alternative Exam Location.
  • If you already have current medical documentation we may accept this in place of Section 2 of this form. The documentation should clearly state your condition, the required exam support(s) and the reason(s) support is required.
  • Please email should you require further advice.

Section 1: Details of Request
What is the medical reason for your request?
What support are you requesting? Please tick the requirement that would be most suitable to you:
Alternative Exam Location (Newman Building)
Extra Time (10 minutes per hour)
Scribe*
Computer
Close to bathroom
Specialist furniture (please specify)
Other (please specify)

PLEASE NOTE:

  • *This supportis dependent on the availability of scribes. In the event that a scribe is unavailable for a particular examination, a digital dictaphone recorder or computer will be necessary to record your examination.
  • NB: It is the responsibility of students who require temporary supports to contact their relevant module coordinators and programme office to notify them of their alternate examination arrangements.

I certify that the details provided above are true and complete:

Signed ______Date______

Section 2: Medical Evidence
Instructions for completion:
  • This form must be completed by an appropriately qualified GP, Medical Consultant or Psychologist.
  • This form must be stamped.
  • Please complete ALL sections below in TYPE or BLOCK capitals.

1. Details of GP, Consultant or Psychologist
Name and Title of Medical Professional:
Phone (including area code):
Position/Professional Credentials:
Date of report:

This report must be accompanied by the medical professional’s stamp, business card or headed paper:

2. Please outline the medical reason(s) for this student requiring temporary exam supports:
Please indicate what exam supports the student requires (tick the supports that would be most suitable in your opinion):
Alternative Exam Location (Newman Building)
Extra Time (10 minutes per hour)
Scribe*
Computer
Close to bathroom
Specialist furniture (please specify)
Other (please specify)
For Internal Use Only
Enquiry taken by / Date
1. Med Cert / 2. Added to Banner
3. Prompt Run / 4. Email Sent
5. Advised Centre / 6. Notes

Please return completed forms to:

Access & Lifelong Learning Centre, Level 1, James Joyce Library Building, Belfield, Dublin 4.

Email: