GRIMSBY INSTITUTE OF FURTHER AND HIGHER EDUCATION
MITIGATING CIRCUMSTANCES FORM
This form should be submitted within 2 weeks of the module assessment deadline
We strongly advise that prior to completing this form you have read the
Mitigating Circumstances Regulations and Guide for Students
(a copy of which can be found at: )
Students who feel they are unable to submit their work should
normally seek an extension in the first instance
STUDENT DETAILS:
Surname: / ………………………………………………… / Forename(s): / ………………………………………………………Programme: / ……………………………………………………………………………………………………………………………………………
Mode of Study:
(Circle as appropriate)
FT / PT / Year of Study:
(Circle as appropriate)
1 2 3 4 5 / Term:
(Circle as appropriate)
1 2 3
Student No: / …………………...... / Academic Year: ……………………………………………..
ADVICE SOUGHT:
This section must be completed by an academic member of staff from your College. A signature must be obtained to confirm that you have received appropriate advice and guidance in making an application.□I have advised the student to submit a Mitigating Circumstances Application
□I have advised the student NOT to submit a Mitigating Circumstances Application
Staff Name: …….………………………………………….. Staff Signature: …….……………………………………………
Date:……………………..………………………….
Please note that staff member signature does not guarantee that your Mitigating Circumstances are granted.
ADVICE NOT SOUGHT:
If unable to consult with a member of academic staff, please state the reason:……………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………
REASON FOR MITIGATING CIRCUMSTANCES: (see Guide for Students on how to state case)
Please state your case. You should write as fully and as clearly as possible, detailing what the problem is and the effect these circumstances have had on you and particularly your studies. You can attach a letter to this form.…………………………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………..
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MODULE DETAILS:
Please list module(s) affected by Mitigating Circumstances:
Module Title / Module Code / Type of Assessment(for example Assignment, Exam, Report, Presentation) / Original Assessment Deadline Date / Actual Submission Date
(if Extension Granted)
(If unsure consult your timetable for the correct Module Code and Module Title, or moodle)
Forms must be submitted within 2 weeks of the original assessment deadline
EVIDENCE TO SUPPORT APPLICATION: (see Guide for Students on what to submit)
Evidence attached:(Please attach any additional information) / YES / NO
YES / NO / 1. ……………………………………………………………………………………………………
2. ……………………………………………………………………………………………………
If “NO” please give date when evidence will be available: ……………………………………………………………………….
LATE CLAIMS:
For forms not submitted within the two week deadline please state reason:...... ……………......
......
...... …………………………………......
STUDENT’S SIGNATURE:
I confirm that all the information supplied is true and accurate to the best of my knowledge. I am aware that a fraudulent application may lead to the University’s Academic Misconduct Regulations (Taught Components and Programmes) being invoked. I acknowledge that it is my responsibility to ensure that I have fully completed this form and the supporting evidence is attached. I understand that any evidence supplied with this form will not be returned. I have read and understood the Mitigating Circumstances Regulations and the Guide for Students. I am aware that any person named in my submission may be contacted in order to seek clarification or further information.Signature: ...... ……………...... Date: ......
GRIMSBY INSTITUTE OF FURTHER AND HIGHER EDUCATION
MITIGATING CIRCUMSTANCES FORM RECEIPT
Students Name: ...... …......
Course: ...... …......
Signature (Student): ...... ……...... Date: ......
Signature (Administration Staff): ...... ……...... Date: ......