1
Emergency Temporary Exam Support Request Form
2015/16 Semester 2 Examinations
Student Name
Student No
Telephone No
UCD Connect Email
address (all
correspondence will be
sent to your UCD Connect
account)
Exam Module
Codes








EMERGENCY TEMPORARY SUPPORT REQUEST
The closing date for receipt of temporary support request forms and accompanying
documentation for the end of Semester 2 2015/16 examinations is 12.00 noon on Friday, 29
April 2016. Emergency requests may be considered after this date with appropriate medical
documentation.
Please note that Assessment, UCD Registry will make every reasonable attempt to
accommodate a student’s request for temporary supports for end of semester examinations.
Temporary support is based on recent medical documentation only. Current and relevant
medical information must be inputted in the section below (see list of accepted medical
professionals below).
If you have a diagnosed disability, significant on-going illness, Specific Learning Difficulty or
mental health condition, you should email disability@ucd.ie and request an appointment to
discuss supports. Specific documentation of a disability is required in order to provide
students with Reasonable Accommodations. Please see Supports for Students with a
Disability for full details.
This form will be retained for a period of 13 months after which time it will be destroyed.
Students with an infectious illness cannot be accommodated in the Alternative Exam
Location.
If you already have current medical documentation we may accept this in place of Section 2
of this form. The documentation should clearly state your condition, the required exam
support(s) and the reason(s) support is required.
Please email temporarysupport@ucd.ie should you require further advice.
Please return completed forms to:
Access & Lifelong Learning Centre, Level 1, James Joyce Library Building, Belfield, Dublin 4.
Email: temporarysupport@ucd.ie
2
Section 1: Details of Request
What is the medical reason for your request?
What support are you requesting? Please tick the requirement that would be most suitable to you:
Alternative Exam Location (Newman
Building)
Extra Time (10 minutes per hour)
Scribe*
Computer
Close to bathroom
Specialist furniture (please specify)
Other (please specify)
PLEASE NOTE:
 *This support is dependent on the availability of scribes. In the event that a scribe is
unavailable for a particular examination, a digital dictaphone recorder or computer will be
necessary to record your examination.
 NB: It is the responsibility of students who require temporary supports to contact their
relevant module coordinators and programme office to notify them of their alternate
examination arrangements.
I certify that the details provided above are true and complete:
Signed _______________________________________
Date________________________________
Please return completed forms to:
Access & Lifelong Learning Centre, Level 1, James Joyce Library Building, Belfield, Dublin 4.
Email: temporarysupport@ucd.ie
3
Section 2: Medical Evidence
Instructions for completion:

This form must be completed by an appropriately qualified GP, Medical Consultant or
Psychologist.

This form must be stamped.

Please complete ALL sections below in TYPE or BLOCK capitals.
1. Details of GP, Consultant or Psychologist
Name and Title of Medical Professional:
Phone (including area code):
Position/Professional Credentials:
Date of report:
This report must be accompanied by the medical professional’s stamp, business card or
headed paper:
OFFICIAL
STAMP
Please return completed forms to:
Access & Lifelong Learning Centre, Level 1, James Joyce Library Building, Belfield, Dublin 4.
Email: temporarysupport@ucd.ie
4
2. Please outline the medical reason(s) for this student requiring temporary exam supports:
Please indicate what exam supports the student requires (tick the supports that would be most
suitable in your opinion):
Alternative Exam Location (Newman
Building)
Extra Time (10 minutes per hour)
Scribe*
Computer
Close to bathroom
Specialist furniture (please specify)
Other (please specify)
For Internal Use Only
Enquiry taken
by
1. Med Cert
3. Prompt Run
5. Advised
Centre
Date
2. Added to
Banner
4. Email Sent
6. Notes
Please return completed forms to:
Access & Lifelong Learning Centre, Level 1, James Joyce Library Building, Belfield, Dublin 4.
Email: temporarysupport@ucd.ie