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					School of Languages, Linguistics and Cultures, LEAP
 Notification of Mitigating Circumstances Form
A form must be filled in with every request for mitigating circumstances to be taken
into account and must be submitted as soon as possible after the event/illness has
occurred and certainly no later than 23 January 2009 (for Semester One coursework
and examinations), no later than 5 June 2009 (for Semester Two).

Do your mitigating circumstances concern (please tick box as appropriate, or both if
necessary):

Problems concerning deadlines of course work/presentations                  

All other assessment performance problems                                   

You should, wherever possible, seek advice from your personal tutor before
submitting this application via the LEAP office (Room SA SG14).

NAME:
REGISTRATION NUMBER:
PROGRAMME OF STUDY:
YEAR OF STUDY:
NAME OF PERSONAL TUTOR:

Please describe the nature of the circumstances or events that you believe have
affected or are affecting your performance or ability to submit coursework by the due
deadline:




Dates of periods affected:


                                                                  PLEASE TURN OVER




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A. ASSESSED COURSEWORK AFFECTED:


Course   Course Unit Title   Name of Course Deadline for    Has your                Is your             Have you asked
Unit                         Unit           submission of   coursework been         coursework          your Personal
Codes                        Convenor/Tutor coursework      submitted? (please      yet to be           Tutor to contact
                                            (Due When)?     indicate clearly        submitted           the Examinations
                                                            YES OR NO and           (please             Committee with
                                                            ADD DATE                indicate            further
                                                            submitted)              clearly YES         information?
                                                                                    OR NO and           (YES OR NO)
                                                                                    ADD DATE
                                                                                    to be
                                                                                    submitted)




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B. EXAMINATIONS/IN-CLASS TESTS OR OTHER ASSESSMENTS AFFECTED:

Course   Course Unit Title    Name of Course Date of       Did you miss your      Did you             Have you asked
Unit/                         Unit           Examination   exam? (please          take the            your Personal
Exam                          Convenor/Tutor               indicate clearly       exam but            Tutor to contact
Codes                                                      YES OR NO)             feel that           the Examinations
                                                                                  your                Committee with
                                                                                  performance         further
                                                                                  was                 information?
                                                                                  affected?           (YES OR NO)
                                                                                  (please
                                                                                  indicate
                                                                                  clearly YES
                                                                                  OR NO)




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NATURE OF SUPPORTING DOCUMENTATION:

It is imperative that supporting evidence is attached – Please tick the relevant
box. Letters from you, the applicant, will not be considered without such
supporting evidence or without written support from your Personal Tutor.

          Self-certification certificate signed by General Practitioner
          Medical certificate signed by medical staff
          Letter from the Counselling Service
          Police Report
          Other (please specify) ___________________________________

Please ensure that confidential material is contained in a sealed envelope.

I confirm hereby that all information given or referred to above is true and that I
believe there has been a significant adverse effect on my performance as a result of
the circumstances and/or events described.


SIGNATURE:


DATE:


For office use only:
Received by:
Date of Receipt:
ACW – Course Unit Convenor contacted (date):
Penalties waived, if applicable (date actioned):
Examinations Officer contacted (date):
Referred to Exams Committee for decision (date):
Mitigating Circumstances Category applied:




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Description: School-of-Modern-Languages