Medical Declaration Form – Exceptional Circumstances
Important Information
Student Universal Support Ireland (SUSI) is committed to protecting the rights and privacy of individuals in accordance
with the Data Protection Acts. SUSI publish a Privacy and Data Protection Statement on their website
https://susi.ie/home/privacy‐statement/susi‐data‐protection‐statement/.
The Information you provide:
Data Processing ‐ What we use it for:
Exceptional circumstances may arise which could impact a student completing a particular period of study or
undertaking exams.
The awarding authority has discretion to award a grant for a repeat period of study in exceptional circumstances
under Article 15(8) of the Student grant Scheme 2022.
The information provided on the attached form will enable SUSI to make a determination under Article 15(8) of the
Student Grant Scheme 2022.
Guidelines for an awarding authority to treat funding for repeat periods of study in exceptional circumstances are
issued each year by the Department of Education and Skills and are available to download from the SUSI website
Data Retention ‐ How long will we hold on to the information provided:
The information provided will be held on file for the duration of the academic year 2022/2023, after which the
information will be securely destroyed.
Data Security ‐ Who has access to this information?
SUSI take appropriate security measures against unauthorised access to, or alteration, disclosure or destruction of the
data and against its accidental loss or destruction. SUSI undertake to ensure that the information provided will only
be accessed by the minimum amount of personnel that is required to make a determination under Article 15(8) of the
Student Grant Scheme 2022.
Explicit Consent
Data Protection Legislation requires explicit consent from the Data Subject in order to obtain and process special
categories of data (e.g. data concerning health). Please see Processing of Sensitive Personal Data/Special Categories
of Data form below. This form must also be completed.
Should you wish to withdraw your consent please email sar@susi.ie and mark for the attention of the Compliance
Officer. Please include the SUSI application number, your name and detailing that you wish to withdraw your consent.
Please Note: Forms that are not signed and stamped by all parties will not be accepted by SUSI. This will result in
delays when processing your application.
F‐SUSI‐0029‐1
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Medical Declaration Form – Exceptional Circumstances
Student Universal Support Ireland is processing a grant application at present on behalf of the
applicant listed below. Any information provided by you to the applicant in respect of their grant
application, will be processed and managed by SUSI in strictest confidence. Data Protection
legislation requires explicit consent from the Data Subject (patient) in order to obtain and process
special categories of data (e.g. Data relating to health). Please also complete the consent section
below.
Applicant’s Name
Applicant’s W
Number
Patient’s Name
The following should be filled out by your designated medical professional
Doctor’s Name
Surgery Name &
Address
Please confirm the date the patient listed above first contacted you in
relation to their illness/symptoms?
Please indicate the time – period over which the circumstances occurred.
From:
To:
Yes
No
Yes
No
Where the applicant and your patient are not the same person, in your
opinion, could the medical circumstances, of your patient, have impacted the
student’s ability to complete their study and/or exams?*
Yes
No
In your opinion are the circumstances likely to re-occur?
In your medical opinion, can you confirm the patient’s medical circumstances
had a direct impact on the applicant’s ability to complete their study and/or
exams?
Please expand with notes, if required.
*If you (the applicant) was prevented from completing the year of your course or the course itself due to the medical circumstances of
another person, please ensure that persons Medical Practitioner completes the medical declaration form
Declaration: I declare that the above information is true and accurate to the best of my knowledge,
Patient’s Signature
Doctor’s Signature
Surgery Stamp (If available)
Please Note: Forms that are not signed and stamped by all parties will not be accepted by SUSI. This will result in
delays when processing your application.
F‐SUSI‐0029‐1
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Processing of Sensitive Personal Data/Special Categories of Data
Student Universal Support Ireland (SUSI) is committed to protecting the rights and privacy of individuals in accordance
with the Data Protection legislation. SUSI publish a Privacy and Data Protection Statement on their website
https://susi.ie/home/privacy‐statement/susi‐data‐protection‐statement/.
Data Protection legislation requires explicit consent from the Data Subject for the processing of sensitive personal
data/special categories of data (e.g. data relating to health).
If the information you are providing relates to ‘sensitive personal data/special categories of data, SUSI requires explicit
consent from the data subject in order to obtain and process this information. For example; if you are providing data
relating to health pertaining to parties of the applications, those parties (Data Subject) must sign the consent below.
If sensitive personal data/special categories of data is in relation to multiple parties to the application (including the
applicant) each party (Data Subjects) must consent to the processing.
SUSI Reference Number:
Applicant Name:
1st Party Name:
2nd Party Name:
Applicant
I ........................................... Consent to SUSI processing the sensitive personal data/special category of data submitted
with this form for the purpose of the Awarding Authority making a determination in relation to the application
referenced above. I understand that I can withdraw this consent at any time.
1st Party
I ........................................... Consent to SUSI processing the sensitive personal data/special category of data submitted
with this form for the purpose of the Awarding Authority making a determination in relation to the application
referenced above. I understand that I can withdraw my consent at any time.
2nd Party
I ........................................... Consent to SUSI processing the sensitive personal data/special category of data submitted
with this form for the purpose of the Awarding Authority making a determination in relation to the application
referenced above. I understand that I can withdraw my consent at any time.
Signed (Applicant): …………………………………………………
Date: ………………………………………………….
Signed (1st Party): …………………………………………………
Date: ………………………………………………….
Signed (2nd Party): …………………………………………………
Date: ………………………………………………….
Please Note: Forms that are not signed and stamped by all parties will not be accepted by SUSI. This will result in
delays when processing your application.
F‐SUSI‐0029‐1
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