Sometimes life puts barriers in the way and additional time is needed in order to comfortably complete your studies.


Students can apply for various types of extensions, please click here for information on the different types of extensions you can apply for.


Please note: you must be enrolled with the University of South Wales to apply for an extension.  If you are not certain about this please look at the following article: How do I enrol with the University of South Wales?



EXTENUATING CIRCUMSTANCES CLAIM FORM


Please read the guidance notes to assist you in the completion of this form.



Section 1: Personal Details



Student ID Number:

Your 8 digit student ID number here

Academic Session:



Year of Study or Cohort:

Cohort eg M22

First Name:

Your First Name/s

Surname:

Your Last Name

Location of Course:

Learna

Course Title:

Write what course you are doing here


STAFF USE ONLY - Ignore this next box it is for USW staff members to complete only


Section 2: Extenuating Circumstances

Use this section to provide details of your extenuating circumstances (What happened? When? How did it affect your studies?) You may continue on a separate sheet if necessary.

  Give details of the reasons for your request for an extension here

Section 3: Supporting Evidence

Use this section to list items of evidence, e.g. GP letter, Death Certificate, Self-Certification etc.

 List the attached letters of evidence to support your claim.  Please note the University will sometimes email you to your personal email account asking for further evidence if the panel finds it insufficient.

Section 4: Late submission of Extenuating Circumstances

Only complete this section if you are making a late claim. You must provide a clear explanation for why your claim is late and this must be supported by independent evidence. You may continue on a separate sheet if necessary.

This is for those making an extension application which is past the submission deadline.  Please try and avoid this where possible and approach them earlier than your submission deadline.


Section 5: Modules Affected

Modules and Assessments

Weighting

Extension

Non-Submission

or Attendance

Original Submission

or Exam Date

Date Requested

for Submission

PE4S153 Disorders of the Thyroid 

REGISTERED  This cell has your module code title, there may be multiple options available, check it is the correct module name / title you are completing

Signature of Lecturer/Supervisor *

Print name:

Tutors Signature n/a
Printed Name of your Tutor

Computer Based/On-line Examination 1 


Fill this row if you want to extend the deadline for your Examination 

30%

Write here what extension you wantTick here if you want a non-submission
date when your assignment was due (see your Examination submission area on Moodle)
What date do you want to submit your work?

Portfolio 1


Fill this row if you want to extend the deadline for your Reflective Journal

10%

Write here what extension you wantTick here if you want a non-submission date when your assignment was due (see your Reflective Journal submission area on Moodle)


What date do you want to submit your work?


Report 1


Fill this row if you want to extend the deadline for your Module Activity

20%

Write here what extension you want
Tick here if you want a non-submission
date when your assignment was due (see your Module Assignment submission area on Moodle)


What date do you want to submit your work?

Set Tasks - not-time constrained 1 


Fill this row if you want to extend the deadline for your Academic Forum

40%

Write here what extension you want
Tick here if you want a non-submission
date when your assignment was due (see your Academic Forum submission area on Moodle)

What date do you want to submit your work?

* Confirming suitability of submission date (actual date will be confirmed by E Circs panel).

Section 6: Third Party Consent

Extenuating circumstance claims are normally only successful where there is evidence that relates specifically to you. Even if your claim is based around the illness or personal circumstances of another person, you must still provide evidence to demonstrate their impact on you. Where you provide the personal information of a third party (relative/friend etc.) a completed Third Party Consent Form must be submitted with this Extenuating Circumstances Form.


You can download the Third Party Consent form here


Section 7: For International non-EU students studying on a Tier 4 VISA


 Ignore this next box



Section 8: Extenuating Circumstances Checklist (please complete)


Tick as appropriate


Section 9: Confirmation



I confirm that I have read and understood the guidance notes before completing this form. I confirm that the details contained on this form are correct to the best of my knowledge. I understand that I may be required to provide additional information in support of my claim. I understand that I cannot add modules to my request once it have been sent to the panel for consideration. The information I have provided relating to my personal circumstances or health is regarded as sensitive and private and will be treated in accordance with the confidentiality code (i.e. excluding certain exceptional circumstances) and will only be used for coordinating my claim and statistical analysis. I am aware that should my claim be successful, the decision will be made available for academic staff within the faculty to view. (Please note that personal circumstances relating to this claim ARE NOT disclosed).


DATA PROTECTION: The University of South Wales will process the personal details collected on this form strictly within the limits of the Data Protection Act 2018 and in accordance with the principles set out in the University's Data Protection Statement.


Signature of Student: Sign here


Date: Write the date here 

Outcome - Decision of the Extenuating Circumstances Panel
Leave this blank for the panel


Claim Approved

Claim Declined

Claim Deferred

Mixed

Notes:

Chair's Signature:

Date:

ACR/Date

ECD/Date

Q+ F/Date

Q+ A/Date

ACR/Updated

ECD/Updated






If you have any questions about completing this form please do book an appointment to chat with Student Services