SELF CERTIFICATION FORM: EXAMINATION / FORMAL ASSESSMENT
STUDENT STATEMENT ON ABSENCE FROM UNIVERSITY
This form must be completed after any period of absence due to sickness or injury that affects your ability to
attend a formal assessment (i.e. examination/test) see the relevant section of the current Student Regulations
Framework, available on Learning Space.
It should account for sickness up to (and including five working days) seven consecutive calendar days
This claim form can be emailed “in confidence” directly to: [email protected]
Student Registration No:___________________________________________________________
Programme of Study:______________________________________________________________
Forename:
__________________________________
Surname:
_________________________________________
I certify that I was unable to attend University due to sickness during the period
from: (day) ___________________
(date) _________________ (1st day of sickness)
to:
(date) _________________ (last day of sickness)
(day) ___________________
A total of _____________ days (to a maximum of five working days only)
Brief description of Sickness or injury (words like 'illness' or 'unwell' are not enough)
_______________________________________________________________________________
_______________________________________________________________________________
Module Affected
Type of Assessment
(Examination/test)
Date(s)
Criteria
EC Panel Use
Only
Decision
Reasons
Name and address of your Doctor:
Name:
_____________________________________________________________
Address:
_____________________________________________________________
* You must be registered with a G.P. in case the Extenuating Circumstances Panel requests additional evidence.
I declare that these details are truthful and accurate and that I am aware of the consequences of
misrepresentation.
Student Signature: __________________________________ Date: ______________
Academic Adviser Signature: __________________________ Date: ______________
Chair of EC Panel Signature: ___________________________Date:______________
This form must be submitted within 7 calendar days of the deadline.
University of St Mark & St John Self Certification – Examination/Formal Assessment Form v5 24/12/15
This Self Certification form must be completed after a period of absence due to sickness or injury that prevents
you from attending examination/formal assessments on a particular date (see the relevant section of the
Student Regulation Framework).
It only covers a single period of 7 calendar days within which the examination/formal assessment(s) were
originally set. All examination/formal assessment(s) must be undertaken at the available opportunity (Resit
Period) as set by the Faculty Administrators. Students are ONLY permitted to use this form for a continuous
assessment deadline ONCE during any academic year.
Registry Services may ask you to complete an Extenuating Circumstances Form attached to a personal
statement (Evidence A) explaining what happened. Normally you will not be required to provide additional
supporting evidence for this single claim. Any further claims for other periods/events in the same
semester/academic year will have to go through the formal procedure of attaching relevant evidence as well as
a brief Personal Statement to a completed Extenuating Circumstances form to submit to Registry Services by
the published deadline.