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.
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Section 1: Personal Details
Student ID Number: | Your 8 digit student ID number here |
Academic Session: |
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Year of Study or Cohort: | Cohort eg M22 |
First Name: | Your First Name/s |
Surname: | Your Last Name
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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
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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 want | Tick 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?
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Portfolio 1
Fill this row if you want to extend the deadline for your Reflective Journal | 10% | Write here what extension you want | Tick 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?
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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)
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What date do you want to submit your work?
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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?
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* 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 |
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If you have any questions about completing this form please do book an appointment to chat with Student Services