Faculty of Medicine and Dentistry Only

Extenuating Circumstances Form (Faculty of Medicine and Dentistry only) Important Notes (please read before completing the form): 1. The purpose of this form is to enable you to inform the Board of Examiners of your programme of any extenuating circumstance(s) that may have affected your ability to fulfil the criteria for the award of credit points or to perform to the best of your ability in assessment events. 2. To enable the Board to make as accurate a judgement as possible on the impact of the circumstance, please ensure you provide as much information as possible on the circumstance, and include evidence (e.g. medical certification) where necessary. The courses of action that a Board of Examiners can employ, where evidence is provided and subsequently classified, is set out in the University’s policy on extenuating circumstances. 3. If you are absent from an examination because of illness, you may self-certify your absence (i.e. not provide medical evidence). In such cases, you must contact your School to notify them of your non-attendance prior to the start of the examination. You must also complete and submit this form, as outlined in (6), indicating in Section 4 that you are self- certifying. 4. In normal circumstances, if you self-certify your absence from an examination due to illness you will be required to undertake the examination without penalty in the next relevant examination period. 5. If you have already been granted extra time to a deadline for the submission of work or alternative arrangements for examinations, you only need to submit this form if you consider the extenuating circumstances to have had a further adverse effect requiring consideration by the Board of Examiners. 6. Please submit the completed form to your School Office. If you are absent during the teaching period, the form must be submitted within two working days of the end of the period of absence. If you are absent from or unable to complete an examination, or, in hindsight, feel that you have not been able to perform to the best of your ability in assessment due to extenuating circumstances, the form should be submitted as soon as possible but before the meeting of the Board of Examiners at which your performance will be considered. 7. Any submitted evidence will be considered in confidence by the Extenuating Circumstances Committee (ECC). If you do not wish the ECC to be aware of the detail of your circumstances, please contact your Faculty Office and arrangements will be made for you to speak to the Faculty Education Director. 8. You may also wish to refer to University policy on the notification of extenuating circumstances at www.bristol.ac.uk/esu/assessment/codeonline.html#extcircs when completing this form. 9. All data is collected, processed and disclosed in accordance with the Data Protection Act 1998.

1) Personal details

Full Name Student Number Student Number Year of Study 1 2 3 4 5 Degree Programme Email Address

2a) Have you spoken with a member of staff about the circumstance? YES / NO If yes, please select the role and provide the name of the person below: Faculty Student Advisor / Pre-Clinical Programme Director / Director of Student Affairs / Academy Dean / Other

For the 2014/15 academic year 2b) Have you already been granted other arrangements in relation to this assessment/situation? YES / NO If yes, please give full details below:

3) Nature of extenuating circumstance

4) Nature of impact upon work Please provide details of the unit(s) affected and the lectures, tutorials, labs, private study and other learning activities, together with the details of the assessment(s), including the date of the assessment, which has been affected by your extenuating circumstance. If you require extra space, please attach continuation sheet.

Unit Code Type of teaching and/or assessment missed Date of teaching Self- (e.g. lecture, tutorial, examination, fieldwork) or assessment certifying? (please indicate which) missed (exams only)

Yes / No

5) Nature of the medical or other evidence If evidence is supplied, please indicate the nature of it below. Also, if you are supplying personal information (including medical records) relating to a living family member or other third party, please confirm (by ticking the box) that you have gained their consent for this information to be disclosed to the University to support your extenuating circumstances

......

6) I certify that the information provided here is correct to the best of my knowledge.

Student’s signature and date

------Receipt of Extenuating Circumstances – to be retained by student as proof of submission Student name: ………………...... …………….……...... Signature: ……...... …………………………..

School/Faculty name: …………………………..…...... Signature: ……...... ……………..……......

For the 2014/15 academic year Date: ……………………………………

For the 2014/15 academic year