Please ensure you have read the appropriate pages in your Programme Handbook before submitting this form. You should seek the advice of the relevant staff member (as detailed in the Programme Handbook), notifying them you are submitting evidence of extenuating circumstances. This form is confidential and will only be viewed by a minimal number of key people in order to make a fair decision on your application.

|Faculty: | |School/Dept/Div: | |
|Surname: | |Forename: | |
|URN: | |Level: | |
|Programme: | |

Please tick the appropriate box to indicate the reason for your Extenuating Circumstances application:
|1. Examinations (including non-attendance) | |Complete sections A, B and C |
|2. Other assessments (including extensions) | | |
|3. Periods of absence from Lectures, Seminars, Practicals etc. | |Complete section B and C |
|4. Suspension of registration (up to 12 months) *[Interrupt] | | |
|5. Suspension of registration (in excess of 12 months) *[Interrupt] | | |
|6. Extension of maximum period of registration | | |

* School of Health and Social Care Students

SECTION A

Please specify clearly the name(s), type of assessment(s), the submission date(s) and time(s) of the assessment(s) which you are applying for extenuating circumstances:

|Module Name and Code(s) |Deadline (date/time) of Coursework and/or Exam date |
| | |

SECTION B

Please provide a summary of the nature of your extenuating circumstance(s). If you are submitting an application for reasons 1, 2 or 3 and it is after the deadline of your coursework, date of exam, or the period of absence, you must also include in your summary below clear reasons to show why you were unable to submit your application before the coursework deadline, exam date or period of absence. The Panel will consider the reasons you give as part of their decision on your application.

|Nature of Extenuating Circumstance(s): |
| |
|Period affected (dates): | |

Section B continues on the following page.

Please note that you are required to submit formal documentary evidence (originals or authorised copies) with this form to support your application (e.g. medical certificate / doctor’s letter, hospital appointment card, letter from counsellor / psychotherapist, copy of death certificate, letter from funeral director, police report, court letter etc.).

|Please specify the documentary evidence you have attached: |
| |

SECTION C

| | |
|Please tick this box to confirm that you have read and understood the University of Surrey’s regulations for extenuating circumstances. | |
|The regulations can be found at: http://www.surrey.ac.uk/calendar/generalregs | |
| | |
|Please tick this box if you have been assessed by ALS and have been granted a Learning Support Adjustment. | |
|Student Signature: | |
|Date: | |

SECTION D – For Office Use Only

Date form received: ______________________________
Date/time of original notification (if different): __________________________

Panel required: Yes / No

If no, decision of authorised person: Accept / Reject Signature: _______________________________
Date: _____________________

If application accepted, revised submission/assessment date:_______________________________

If panel required, panel members’ names: ______________________________________________________________________________

__________________________________________________________________________________________________________________

Summary of Panel findings:

| |

Decision of panel: Accept / Reject

____________________________________________________________ _______________________________________________
Signature of panel Chair Date of panel
January 2012
-----------------------
C O N F I D E N T I A L
Application for the Consideration of Extenuating Circumstances