1. .

Foundation and Pathways Department, Swinburne University

Application for
SPECIAL CONSIDERATION IN ASSESSMENT    (Which includes Special Examination)

INSTRUCTIONS:	Please read carefully before completing this application.  Make sure you fill in all required details, or the application cannot be assessed.

1.	The eligibility for special consideration is detailed in Student Assessment and Appeals Policy and Procedure, located on the University website: http://www.swinburne.edu.au/corporate/registrar/ppd/docs/AssessmentandAppealsTAFE.pdf
2.	This application must be lodged in HARD COPY with Student HQ, in SPW or AMDC Building no later than 5pm on the third working day after the submission date for a piece of assessment/exam for which Special Consideration is claimed.
3.	To be eligible for Special Consideration (which includes Special Examination) a student must meet one of the following criteria below:
3.1  At any time, a student’s study during the academic year has to a significant degree been hampered by illness or other extraordinary cause; or 
3.2  A student has been prevented by illness or other extraordinary cause from preparing or presenting for all or part of a component of assessment
such as assignments and examinations; or
3.3	  A student has been, to a significant degree, adversely affected by illness or other extraordinary cause during the performance of a component of assessment; and
3.4	  A student has met all other mandatory criteria necessary for successful completion of the subject (e.g. submitting all other mandatory assignments, etc).
The application will be considered on the basis of the evidence presented to support the case, provided that:
ƒ  The completed and signed application form is lodged no later than 5.00pm of the due date of the assessment; and
ƒ  The circumstances (illness or extraordinary cause) were reasonably beyond the student’s control; and
ƒ  The circumstances (illness or extraordinary cause) significantly hampered the student’s performance; and
ƒ  The appropriate supporting documentation is attached to the application and Section E has been signed and stamped by a Medical practitioner and/or Counsellor.

OTHER RELEVANT INFORMATION
An application made after the relevant date, or not on the approved form, may be lodged with Student HQ for evaluation by the Course Teacher. In circumstances where the Course Teacher is satisfied that it was not possible for the application to have been made on the prescribed form or on an earlier date, the application will be evaluated. It should be anticipated, however, that late application will not normally be accepted.

The Department will advise student of the outcome of this application within five (5) days of receipt of the application

SECTION A	Personal Details – All Fields Required to be completed		
STUDENT ID			
FAMILY NAME			
GIVEN NAMES			
ADRESS			
SUBURB	Postcode:		
PHONE	Mobile:		
EMAIL ADDRESS			

SECTION B	Course Enrolled  - Required	
Course Code	Course Title	Course Start Date	Full- or Part-Time	

SECTION C	Unit/s in which Special Consideration is sought – All Fields required to be completed	
Unit of Study Code	Unit Title	Exam or Course work	Class Code & Semester	Due date	

					

					
Please state reason for application. Documentary evidence must be supplied				

	
	
SECTION D	Student Declaration – All Fields Required to be completed	
I hereby apply for Special Consideration for the stated units of study. I declare that the information I have provided in this application and on the attached documentation is true and correct in every detail. Where a medical certificate and/or supporting statement is attached, I Authorise Swinburne University of Technology to seek information directly from the originating source. I have read and understand the guidelines printed on this form.	
STUDENT Signature:	DATE:	

SECTION E	Medical Impact Statement – All Fields Required to be completed	

Examination affected by medical condition/other condition
In my opinion the student was disadvantaged at all or some examinations (please tick appropriate box and specify period)
□	totally, unable to sit exam(s) – specify period  	
□	severely, unable to sit – specify period  	
□	moderately, but able to sit – specify period  	
□	slightly, but able to sit – specify period  	
Other assessment and/or examination preparation affected by medical condition/other condition (please tick appropriate box and specify period)
□severely	□ moderately	□slightly 	
Ongoing disadvantage caused by medical condition/other condition
In my opinion the student’s condition will continue to cause disadvantage   (If this item is completed the student will be informed of Disability Services)
□For the predicted period ending	□ ongoing  	

SECTION F	Medical Practitioner or Counsellor Declaration	From	To	

Specify period of Special Consideration due to Medical Condition			
Medical Practitioners name:

Counsellors Name:	Telephone:

Telephone:		
Medical Practitioners Signature and Stamp:	

SECTION G	TO BE COMPLETED BY	AUTHORISED ACADEMIC OFFICER	
DEPARTMENT NAME:	DATERECEIVED:		

Special Consideration Outcome (please circle one)	Approved
eligible for special examination/course work	
Not Approved
reason must be given	
NOT APPROVED: Reason/Comments:	

APPROVED: Give details of Special Consideration granted for each unit of study applied for, eg allowed to resit exam (give date by which resit or course work is due)	
Unit of Study code	Unit Title	Exam or Course work	Outcome/due date	

				

				

				

				
Comments or Reason for Outcome/dates:	

	
Name of Manager or Senior Educator	
Signature:	Date:	
Applicant notified in WRITING of outcome by:

Name	Initials	Date:	

DEPARTMENT TO SUBMIT ORIGINAL FORM TO STUDENT PROGRESS OFFICER WITHIN 2 DAYS OF APPROVAL

Student Progress Officer date received:	
Student Progress Officer date ‘DEF’ result entered:	Initials:	
PRIVACY: Swinburne University of Technology collects, uses and destroys your information with our Privacy Policy, which can be found at: http://www.swinburne.edu.au/privacy.htm
All applications for Special consideration will be treated as strictly confidential.