UCL School of Pharmacy
Extenuating Circumstances/Extension Request Form
Before you complete this form please read the Extenuating Circumstances Policy available on the School
website under Student Life/School Regulations. The School operates a FIT TO SIT policy which means
that if you sit an examination or submit coursework you are declaring yourself fit to do so and
cannot later make a claim for extenuating circumstances. Please note that being embarrassed about
your circumstances will not be accepted as a valid reason under the Appeals Policy for not submitting
them.
Please complete all sections of this form and attach relevant independent documentary evidence. Please
type in the grey text boxes below. You can move between text boxes by using the tab key on your
keyboard.
Title (Mr/Ms etc)
UCL ID No.
First Name
Surname
Programme
Year of
study
UCL Email
Contact Address
We will only use the address you hold on Portico. Please ensure this is up to date.
Assessment Type1: EX Exam; CW Coursework; PR Practical; PJ Project; OR Presentation; TE Test.
Assessment Date2: Date of Exam/test/presentation or deadline for coursework
Outcome3:
A = First attempt at next available opportunity (normally in the September resit period)
B = Extension to coursework deadline (write the length of Extension requested i.e. 1
week.
Please complete a line for each type of assessment affected
Module Code
i.e. PHAY1000
Assignment Description
i.e. Chemistry Practical/Essay 1/MCQ Test
Type1
Date2
Outcome3
SUMMARY OF ECs: Please indicate which category your extenuating circumstances fall into by checking
the appropriate box and provide a brief summary of the circumstances in the box below:
Illness/Injury/Hospitalisation
Significant personal problems/trauma
Illness of a dependent/relative
Victim of crime
Bereavement
Other
Summary (maximum 100 words):
PERSONAL STATEMENT: Please provide the following information about your Extenuating
Circumstances:
 A description of the ECs
 How the ECs have affected your assessment
 How were the ECs outside of your control
 The dates that you were affected by the ECs
Please write clearly and concisely and only include relevant information to enable the Extenuating
Circumstances Panel to assess your claim. You may continue on one sheet of A4 paper maximum.
Maximum (300 words)
DOCUMENTARY EVIDENCE: Please state what documentary evidence you are submitting to support this
EC claim. If you have not been able to supply documentary evidence with this claim, please state the date
by which it will be provided.
Independent Documentary Evidence
Date evidence will be
supplied
DECLARATION
I declare that I have read and understood the School’s Extenuating Circumstances Policy and that the
information I have provided on this form is true and factually correct. I understand that:

The School operates a Fit to Sit Policy and by sitting an assessment I am declaring myself fit to do
so.
Submitting a claim for ECs does not guarantee that the claim will be accepted.
If ECs are accepted for the September exam period this may require a deferral of studies for up to a
year.


Student’s Signature: _______________________________________ Date: _____________________
Return the EC Form and documentary evidence, to the Student and Academic Support Office
(Room G11) by the following deadlines. Please retain a photocopy of the form and your
documentary evidence for your own records.
If ECs occur before an assessment has taken place then the EC claim must be submitted at that time.
If the ECs occur at the time of the assessment then they should be submitted by the following deadlines:



Coursework/Project within 7 working days after the coursework/project deadline
Tests/Presentations within 7 working days after the date of the test/presentation
Examinations
within 7 working days after the date of the last affected exam
EC Panel use only:
Decision:
ACCEPT / REJECT
Reason (if declined):
Signature required if decision taken by Chair’s Action
Signature of Chair:
_________________________________________ Date: _____________________