SPECIAL CONSIDERATION REQUEST FORM (Medical Grounds)

Students applying for special consideration must submit this form along with complete supporting evidence within 3 working days of the due date of the assessment item or exam. Please note that we will take into account the following details when considering the special consideration application:-

Your performance in other assessment tasks in the unit;
The history of your special consideration request;
The severity of the event;
Your academic standing in other units and in the course; and
Your supporting evidence such as Medical Impact Statement and medical certificates

Important Note: The application may be rejected without supporting documentation. If the supporting documentation is in a language other than English, you must supply copies of the original language document/s, and a complete English translation of the original language document/s.

Students will be advised of the outcome within five (5) working days. Supporting evidence should be attached.

For further information please refer to the Student Assessment Policy and associated Procedure available on the Australian Institute of Higher Education website: www.aih.nsw.edu.au

Please contact Student Services (studentservices@aih.edu.au) if you have any further queries.

PERSONAL DETAILS

Student ID: *

Title: *

Mr

Ms

Mrs

Other (please specify) Other (please specify)

First name(s): *

Family name: *

Sex: *

Male

Female

Date of birth (dd/mm/yyyy): * +

Phone (home/mobile): *

Email address: *

Full Address: *

City: *

State: *

Post code: *

Country: *

Course: *

UNIT INFORMATION

Unit code: *

Unit name: *

Semester and year this request related to: *

Block: * 🛈

Assessment Number: * 🛈

A1

A2

A3

Other Other

Assessment weighting (%): *

Assessment due date (dd/mm/yyyy): * +

Details of assessment(s) special consideration is being applied for: *

Reason(s) for applying for special consideration: *

The following items must be uploaded for applying for Special Consideration on medical grounds:

1. Upload a Special Consideration Medical Impact Statement which is duly filled by a registered medical practitioner, registered psychologist or registered counsellor.

2. Upload your Medical Certificate below

Special Consideration Medical Impact Statement upload: *

Medical certificate upload: *

Any other evidence upload:

Outcome sought: *

Please note that sufficient evidence must be provided for special consideration to be approved.

Incomplete applications will not be processed.

STUDENT DECLARATION

I declare that the information provided in this application is accurate. I have read and I understand the Student Assessment Policy and associated Procedure.

Student's signature *

clear

Date: *

Privacy: We recommend that you read the AIH's Management of Personal Infomation Policy and associated Procedure published on our website [www.aih.nsw.edu.au]