Uni ID

User code

Full name

Email

Course of study currently registered for: *

Mode of Study

---- Part-time Full-time Distance Learning Other

Please state the type of mitigation you are presenting (you may select more than one type and if other please provide details): *

Other - please provide further information

Period affected (please give start and end date) *

Modules and assessment(s) affected (including details of any deadline dates) *

Please provide further details of how the mitigating circumstances have affected your learning or assessments (relevance) *

Please provide further details of how severely the mitigating circumstances have affected you/ your learning and/or assessment (severity): *

Please indicate who you have contacted in relation to your mitigating circumstances (please select more than one option if applicable) *

If you have answered other or did not ask for help above please provide further details

Have you been granted an extension or taken Temporary Withdrawal (TWD) for this Mitigating Circumstance already *

If yes - please provide details if extensions granted / periods of TWD etc

Please give details of the evidence of your mitigating circumstances which you are providing or intend to provide with this form *

---- Doctor’s note/Fit note/Statement of Fitness for Work Letter from GP or Consultant confirming the circumstance and attesting to its impact on the student Statement from Personal Tutor / Student Support or counsellor attesting to the impact of the circumstance on the student Specific Learning Difference diagnosis letter Other letter e.g. from Disability Services, employer Copy of death certificate Other formal documentation e.g. Court Summons, police report Other evidence (please specify)

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PART TIME STUDENTS ONLY Have you been granted sick leave from work for this Mitigating Circumstance *

If you have selected other for evidence above please provide further details

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Please indicate which exam board recommendation you are seeking through this claim: *

If you selected other please provide further information fo the recommendation you are seeking

Privacy statement

Please note that the information you provide will be reviewed by the departmental mitigating circumstances pre-board in order to make a recommendation to the Board of Examiners about your case. The University will keep your full student record for six years after the end of the academic year in which you graduate from, other otherwise leave the University. After six years, the University will retain only the data necessary to identify you and confirm the dates you studied at the University, the degree and classification you were awarded and a transcript of your marks. All other personal data on your student record will be disposed of in a secure manner.

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