Extenuating Circumstance Form
Undergraduate and Postgraduate Taught students
This form is for students submitting evidence of medical or personal circumstances that they wish to be considered in relation to:



Assessments, including examinations and coursework
None or late submission of coursework
Absence from class/study of more than 7 calendar days
If you have been absent for less than 7 calendar days and no assessment is involved, you should normally self-certify that absence
without evidence.
See https://students.sheffield.ac.uk/extenuating-circumstances for more information.
Please read the guidance on extenuating circumstances on the above page before completing this form. If you need further guidance,
please talk to departmental staff, the Student Advice Centre or SSiD.
If you are registered with the University Health Service (UHS) please send the form as a Word document
to sheccg.universityhealthservice@nhs.net
1. Student’s Details
2. Student’s Details
Registration Number:
Are you studying in the UK on a student visa? Yes
No
210195747
Family Name:
First Name(s):
Navid
Date of Birth:
Soban
University email address:
20/11/1998
First year
Program and Year of Study
Student Signature:
Snavid2@sheffield.com
Soban
Date:
15/12/2021
I confirm that the information I have given on this form is correct to the best of my knowledge. I understand that appropriate University
academic and support staff will have access to the information I have provided on this form
2
Module Information
2. Units Affected by Extenuating Circumstances
What units are affected and what action are you requesting as a result of these circumstances? PLEASE NOTE: your request will be
considered in line with your existing academic departmental practice and will only be granted where circumstances are considered to
be extenuating.
Unit Code
(inc Achieve
More if
appropriate)
~If appropriate, Assessment
Type(s) (e.g. assignment,
exam, quiz, lab). Please
include all affected
assessments for the unit(s)
in question
Dates affected: from and
to
Requested
Action
6025
Online assessment
DEX
6075
Online assessment
6022
Online assessment
17 January- 28
January
17 January- 28
January
17 January- 28
January
DEX
What action are you requesting?
Please insert code(s) below in ‘Requested Action ‘
column:

Not Assessed (another attempt permitted
without capping grade) = NA

No penalty for late submission = NP

Deadline Extension = DEX

Authorised Absence = AU

Consideration by Exam Board = EB

For Information Only = IO
DEX
Not all actions may be appropriate for all assessments.
If you are unsure what to request please contact your
departmental adviser.
Please insert a * next to the unit code if any of the units
listed are Languages for All (LFA) units. You must also
provide the academic department providing your LFA
unit(s) with a copy of the form.
3. Duration of Circumstances
From:
To:
or On-going (please tick):

4. Details of Circumstances
You must provide details of any circumstances relating to C, D and E below and attach any supporting evidence, e.g. letter from
counsellor, social worker, hospital (re close relative/significant other), staff member etc., Learning Support Plan (LSP), police crime
number etc.
If you wish any details to remain confidential you should include them separately in a sealed envelope marked for the attention of your
personal tutor or other appropriate departmental staff. Submit the envelope with this form. Please tick the box if a separate envelope is
attached with this form.
Please select (√) the relevant box to indicate the type of extenuating circumstances
A. Serious short term
illness/accident/hospitalization*
resulting in absence for more than 7 calendar
days/affecting assessment.
Are you registered with the University Health Service (UHS)?
YES: ��
NO:
�
*delete as appropriate
If you have indicated YES, in box 4a below, please provide the name of
the health care professional you saw in relation to your extenuating
circumstance and the dates you were seen by UHS.
B. A deterioration or fluctuation of a disability/long
term health condition, resulting in absence of more
than 7 calendar days and/or affecting assessment.**
C. Bereavement
√
D. Significant adverse personal/family
circumstances
E. Other significant exceptional factors (including
non-medical circumstances)
F. Frequent absence of less than 7 calendar days
where no assessment is involved
Students should normally self-certify
(https://students.sheffield.ac.uk/extenuating-circumstances) unless such
absences are frequent enough to cause concern.
**A Learning Support Plan (LSP) from the Disability and Dyslexia Support Service (DDSS): https://students.sheffield.ac.uk/disability or a medical
statement may already make relevant support recommendations. Academic Departments should check the LSP or medical statement but also
note that these recommendations are not exhaustive and cannot cover all circumstances.
4.a: Please provide details of your extenuating circumstances (continue on a separate sheet if necessary):
I am applying for extenuating circumstances for this assignment because my circumstances have drastically changed. I am a
registered carer for my vulnerable grandmother. Previously, I was able to maintain a steady workload but that has changed. On
Wednesday I realised I lost my sense of taste but felt ok. So, I went to the walking centre to check if I didn't have covid and get some
tests. The nurse said I probably had long covid and didn't know about it. So, the symptoms would stay with me afterwards. Tests
came back negative. But it was the following days when my health started to deteriorate. I woke up with headaches and tired.
losing my sense of taste and smell has also impacted me mentally. But more importantly, my grandmother is shielding, which has
forced me to care for her on a full-time basis which is taking up most of my time. This added responsibility has impeded my ability to
study. I also suffered from insomnia, which was caused by anxiety and stress, which had resulted in the use of prescription
medication which also make me drowsy during the day. I have attempted to attend as many seminars as possible but due to the
symptoms corresponding with covid and the flu I’ve stayed at home. Due to my caring responsibilities in tandem with trying to deal
with the symptoms of covid my studies have been affected. So, I haven't been able to make headway in completing the essay the way
I want. I have booked an appointment with my GP in advance if the symptoms get worse. I will be getting a doctor’s note illustrating
my deteriorating condition. I will also send this document to my GP to fill in the appropriate section also clarifying my condition.
5. Medical Evidence to be completed by a Medical Practitioner, if appropriate (see 4A above)
Diagnosis/Condition and Brief description: covid symptoms and anxiety
Is the impact of this on the patients academic work likely to be:
Minimal
Moderate
Significant
Did you see the patient at the time of the injury/illness: Yes
Name and Signature of Medical Practitioner Completing this form:
No
Practice Stamp:
Date:
6. Departmental Details
This section should be completed by the academic department requiring the information on the extenuating circumstances
Name of staff member of departmental staff co-ordinating the report:
Email address:
Date form received in Department:
Departmental Comments:
Note to University Staff: Please email a copy of the completed form to your usual Student Results and Awards Team contact, at their
sas.XXXX@sheffield.ac.uk email address. Contact details can be found at: https://staff.sheffield.ac.uk/student-support-services/about/sas-staff