AMC Department of Health and Human Sciences

CONFIDENTIAL EXTENUATING CIRCUMSTANCES FORM This form is ONLY for use by under r!du!"e s"uden"s #hose modu$e is %!r" of ! he!$"h %rofessions &u!$ifi'!"ion( FULL NAME) REGISTRATION NUM*ER) COURSE) DE+ARTMENT) YEAR OF STUDY ,ST YEAR - .ND YEAR - /RD YEAR - 0T1 YEAR Please complete your claim overleaf: FOR OFFICE USE ONLY: D!"e re'ei2ed by AMC) Ou"'ome Re'ommended by AMC Commen"s) SU++ORT +ARTIAL SU++ORT DO NOT SU++ORT

Si n!"ure of Ch!ir of AMC) D!"e) Co%ied "o) This form should be completed if you want to make the Extenuating Circumstances Committee !oard of Examiners aware of any extenuating circumstances which you belie"e may ha"e ad"ersely affected your performance either during the year or in the examinations# +$e!se re!d "he no"es for uid!n'e before 'om%$e"in "he se'"ions #hi'h !%%$y "o you( $ou need to submit . 'o%ies of the form and any documentation to the Department of Health and Human Sciences %eception within se"en days of the published assignment deadline# &t is important to realise that only the most serious extenuating circumstances are likely to ha"e a significant effect on your o"erall results# 'lease take time to assess your situation carefully and only submit details of extenuating circumstances if you are sure that they ha"e significantly affected the (uality of your work# %emember that the !oard of Examiners will be looking at the affected work in the context of the rest of your work throughout the year)s* and is unlikely to take extenuating circumstances into account unless it is apparent that the work in (uestion is of a significantly lower standard# The *o!rd of E3!miners #i$$ no" 'h!n e m!r4s !#!rded5 bu" #i$$ !ssess #he"her your %erform!n'e h!d been !d2erse$y !ffe'"ed !nd #i$$ "!4e "his in"o !''oun" #hen m!4in de'isions !bou" s"uden" %ro ress or de ree '$!ssifi'!"ion#

!6 If you be$ie2e your %erform!n'e in !ny !ssessed #or4 durin "he ye!r #!s si nifi'!n"$y im%!ired or you #ere un!b$e "o submi" "he #or45 %$e!se $is" "he !ffe'"ed #or4 !nd des'ribe ho# i" #!s !ffe'"ed 7 in'$udin d!"es of "he %eriod 'o2ered( +eriod Affe'"ed Course#or4 Affe'"ed !nd De!d$ine De"!i$s of E3"enu!"in Cir'ums"!n'es !nd ho# "hey h!2e !ffe'"ed your #or4

b6 List below the documentation which you have attached in support of your statement (Please note that AMC will NOT seek evidence on your behalf it is your responsibility to do this!" AMC reserves the ri#ht to check on the validity of the document(s! you submit by contactin# the third party directly" The $%tenuatin# Circumstances Committee reserves the ri#ht to re&ect cases where evidence is not provided"
(Please do not state that xxx is available if needed - If you list documentary evidence to support this claim you ARE re uired to submit it!"

'6 You shou$d no"e "h!" submi""in ! f!$se '$!im or fr!udu$en" do'umen"!"ion is ! serious m!""er !nd is !n !'!demi' offen'e5 #hi'h #i$$ be de!$" #i"h under "he A'!demi' Offen'es +ro'edures( AMC reser2es "he ri h" "o 'he'4 on "he 2!$idi"y of "he do'umen" 8s6 you submi" by 'on"!'"in "he "hird %!r"y dire'"$y( I 'onfirm "h!" "he inform!"ion I h!2e i2en is "rue !nd "h!" I h!2e re!d !nd unders"ood "he uide$ines on e3"enu!"in 'ir'ums"!n'es(

SIGNED)

DATED)

%eturn . CO+IES of this form and supporting documentation to the Department of Health and Human Sciences %egistry ,ffice within se"en days of the published assignment deadline# -orms will not normally be accepted after the deadline unless there is a clear reason why the form could not be submitted on time#

Medi'!$ E2iden'e +roform! /hen you ha"e completed Section +0 it is your responsibility to take this form to your Medical 'ractice for completion of Section .# AMC #i$$ no" e" "his si ned on your beh!$f( The form will then be returned to you so you can attach it to your extenuating circumstances form# &f other 'ractices prefer to use their own procedures0 you should attach whate"er documentation they gi"e you# Se'"ion , "o be 'om%$e"ed by "he s"uden" Student 1ame2 33333333333333333#33333# Date of !irth2 33333##33##

& state that my work has been se"erely affected by the following medical condition2 Medical Condition2 33333333333333333333#3333333333333333 Date)s* Affected2 3333333333333333333333333333333333333 & am asking my Medical 'ractice to "alidate this claim and return the document to me# & am signing below to gi"e my consent for this information to be supplied under the terms of the Access to Medical %ecords Act +445#

Student signature2 33333333333333333##

Date2 333333333

NO9 TA:E T1IS FORM TO YOUR 1EALT1 CENTRE-MEDICAL +RACTICE ; 9E 9ILL NOT GET IT SIGNED ON YOUR *E1ALF Se'"ion . "o be 'om%$e"ed by 1e!$"h Cen"re-Medi'!$ +r!'"i'e -ollowing the student6s re(uest0 we can confirm that the student2 a* b* c* d* e* Has had a significant condition that should be taken into account# Has had a condition that may be taken into account# There is no clinical e"idence to support their statement2 &s unfit to sit an examination on )date)s*333333333##* ,ther comments#

1ame2333333333333333333333 Date23333333333333#33333333#

Signed33333333## +r!'"i'e S"!m%)