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For Office Use Only:

Received On : __________ Received by : __________ Time : __________

Acknowledgment of receipt of EC Form

Time : __________

Module : Student ID No.: __________ Received On : ____________ Acknowledged By : ________


You should give this form to UCTI Administration. Failure to complete all sections of this form may result in rejection by the EC committee. If you require complete confidentiality submit to the UCTI Administrator in a sealed envelope addressed to the Chair of the EC Committee and labelled EC Application confidential


Please indicate AGAI ST EACH MODULE you list below the effect of the circumstance that you are claiming for by using the following codes: L = Late Submission M = Performance was affected by mitigating circumstances (These are circumstances which have caused you to perform less well than you would have otherwise done) N = Non-attendance at an exam or non-submission of course work You must complete this section if your circumstances have affected a piece or series of assessments due for submission on a given date (e.g. essay, project etc.) or if your circumstances have affected an element of assessment/s for which you are/were required to attend (e.g. exam, class/lab test, presentation).
List only those modules for which you are claiming extenuating circumstances. You must complete all of the boxes for each module affected Module Module Title Module Tutor Assessment Type Required Actual Type of Code i.e. exam, project etc, Submission Submission circumstance State all assessments Date/s Date/s (you MUST affected for each use the codes module above)


You must complete this section of the form. After you have completed the entire form fold this section on the dotted line and staple, before you hand it in to the UCTI administrator, to ensure it remains anonymous

Fold and Staple here


Student ID No:



Address (to which you want the Panels decision to be sent):

Email Address:

Telephone Number: Signature: Date:

I confirm that to the best of my knowledge the information given on this form is a true and accurate statement of my personal circumstances. I understand that details of this claim will remain confidential to the panel except in certain circumstances detailed in the procedures.

Ensure you have your receipt for submission of this form

Issue 1.0 December 2009 EC_Req

PART C: DETAILS OF CIRCUMSTA CES Please give brief details of your circumstances do not exceed the space provided.


Do you have supporting evidence in relation to your claim? Yes No If NO, then a supporting statement will be required by the Extenuating Circumstances Panel. This may be provided where appropriate by your Programme Leader, Class Mentor, Module Tutor, Welfare Counsellor or other independent suitably qualified person. If your extenuating circumstances are medically related supporting evidence must be provided by your Doctor or counsellor. If you have not included a doctors note a Statement must be completed by your Doctor, Counsellor, UCTI Tutor or other people suitably qualified to provide an opinion/supporting statement on your circumstances.

Name: Contact Address:


Telephone No:


Date: Official Stamp:

If the circumstance covers more than one module/course component, part C need only be completed once. Please provide a brief outline of the extent to which, in your professional judgement, the student was/will be affected by the circumstances and the dates to which his/her circumstances apply.

Supporting Statement

Issue 1.0 December 2009



Part A Part B Part C

All the boxes in the table completed All your personal details completed fully The circumstances affecting your work are fully explained

Supporting Evidence Relevant supporting Evidence attached and/or Part D Completed fully

Latest Drafts of work attached as proof of work completed (if required) ___________________________________________________________________________________ PART F: FLOWCHART OF PROCEDURES Collect Form

Complete form and attach relevant evidence

Hand in form to UCTI Administration including latest drafts of work as proof of the work youve done (if appropriate)

Obtain acknowledgement receipt The Panel meets once each month and your claim will be considered at the next meeting following your submission of this Form

Extenuating Circumstances Panel Meets

Panels decision notified to you. Appeal UPHELD Decide to accept grade awarded or submit for further assessment Appeal NOT UPHELD Appeal against the decision by writing to Operations Manager within 7 working days of receipt of Panels decision. For modules at level 2 and 3 it will then be sent to Staffordshire University for consideration

Issue 1.0 December 2009

For UCTI Office Use: __________________________________________________________________________________________ Date Considered:

Late Submission Non Attendance Mitigating Circumstances

Upheld Upheld Upheld

Rejected Rejected Rejected

Deferred Deferred Deferred


Reasons for Decision:

Issue 1.0 December 2009