Student Administration M356, 35 Stirling Highway CRAWLEY Western Australia 6009 Phone: +61 8 6488 3235 Fax: +61

8 6488 1083 www.studentadmin.uwa.edu.au www.ipoint.uwa.edu.au

CRICOS Provider Code: 00126G

application for special consideration

Student ID

Part 1
To make an application for special consideration, complete sections 1, 2, 3 and 5 of Part 1 and section 6 of Part 2. You should sign and date section 9 of Part 2 in the presence of the report provider.

Personal Details
Dr/Mr/Ms/Mrs/Miss Given Names Contact Address Suburb Daytime Telephone Email Course Faculty State Mobile Postcode Family Name

Application
Applications due to illness must be accompanied by a signed doctors report provided in Part 2 or on separate documentation provided by your doctor. Applications based on other grounds must be supported by an appropriate person providing a summary statement in Part 2 or on separate documentation.

I am making this application due to: Illness Other Grounds

Declaration
I certify that the information provided is correct. I authorise release of personal information to appropriate staff of the University only on the conditions described overleaf. Signature of Student________________________________________________________________ Date________________________________ Please see additional pages to be completed by the student!

Faculty/School Office use only

Approved Exams Office Notified Partially Approved Student Notified Not Approved Student Services Notified Callista ID_______________________________

Name of Authorising Person_____________________________________________________ Position of Authorising Person___________________________________________________ Signature of Authorising Person__________________________________________________

Date___________________________________

Faculty/School: Please forward Part 1 to Student Administration for data entry into Callista SMS

Student ID

5
Office Use Only Date Exam/ Asessment Due Outcome Code (see below) Authorising Officer signature

To be completed by the Student

Students should enter Semester, Year, Unit Code, Unit Name, Request Code and Date Exam/Assess due ONLY Request Code (see below)

Semester

Year

Unit Code/s

Unit Name

2
Outcome Codes to be entered by Authorising Officer ONLY DECLiNED DEF-EXAM DiSC-MARK EXTENSiON REFERRED RESCHED-EX SPECiAL-AR WiTHDRAW Special consideration application not approved Defer exam Special consideration approved, assess with discretion Variation to assessment deadlines Special consideration application referred to school Rescheduled exam Special exam arrangements Withdraw without penalty

Key to Request Codes

TSV

Variation to assessment deadlines

Please give details of extensions or other accomodations sought, if any:

SCAA

Discretionary marking

DE

Deferred exam

WD

Withdrawal without academic penalty

Other

Student ID Application for Special Consideration Part 2 Confidential

6 Explanation for Application for Special Consideration
Student Name The reasons for my request for special consideration, as outlined above, are as follows:

Report Supporting Application for Special Consideration

To be completed as appropriate by Medical Practitioner, UWA Student Services practitioner, academic staff member, Guild Education Officer, College Principal or other person able to provide an objective assessment of the applicants circumstances, eg: religious leader Date of onset of illness/circumstances Expected duration of illness/circumstances Date student seen

Please complete at least one of the following categories: The student is suffering from (Diagnosis provided with patient consent) or The student states that he/she is/was

Further comments

(attach extended statement if necessary) In my opinion the students medical condition is/circumstances are affecting performance in the areas indicated: from __________________________ to ___________________________ No effect Lectures Assignments Practical sessions Private study Examinations To your personal knowledge has the student consulted you or a professional colleague on this matter previously? Yes No Dont know in a minor way Moderately Severely Unable to assess

Report Provider Details

To be completed by the report provider Name Business Address Suburb Daytime Telephone Signature State Date Official Stamp Postcode Occupation

Confidentiality Statement
To be completed by the student in the presence of the report provider I understand that the information above will be kept confidential and only discussed with appropriate staff of the University on an as-needs basis. Signature of Student________________________________________________________________ Student ID________________________________________________________________________ Date________________________________

REG_0009_05/10