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Sample Extenuating Circumstances Claim Form

Sample Extenuating Circumstances Claim Form

This is for information only – please ask your academic school for a form.


Postgraduate Subject Examination Board for Classics

This form should be used by all taught course students to make claims for extenuating circumstances relating to missed examinations and assessments and non-submission of coursework, including extensions to coursework deadlines.

To be considered by the Subject Examination Board, students must complete all parts of this form and return it - together with appropriate documentary evidence – to XXXXXXXXXXXXX. Claims submitted without supporting documentary evidence will not be considered

Students must submit claims as soon as possible, and at the latest by XXXXXX. Claims submitted after this deadline will not be considered.

It is recommended that students read the student guidance booklet called Extenuating Circumstances available from the Advice and Counselling Service and online at, and seek advice from academic advisors, senior tutors or school or institute administrators before completing the form.

Please complete this form using a word processor, or use a pen and write in block capitals if completing by hand.

Personal details

Student ID number:






Contact address (term-time):

1 Avenue Way



AB12 3CD

Telephone number:

09876 543210

Alternative telephone number:

01234 567890

Queen Mary University of London email address:

Study details

Programme of study (e.g. BA French):

MA Classics

Year of study (0 - 7 or Masters):


Personal tutor:

Dr J. Smith

Details of claim

Please continue on a separate sheet if necessary.

Module code

Element of assessment e.g. examination, coursework

Examination date/

submission deadline

Did you attend/




4 May 2012




14 May 2012



Summary of extenuating circumstances

Please use the space below to explain your extenuating circumstances, and how these meet the following criteria. In order to be valid, the extenuating circumstances must be:

  • unplanned;
  • outside of the student’s control;
  • such that there has been a negative impact on the ability to undertake or complete any assessment;
  • cast doubt on the likely validity of the assessment as a measure of the student’s achievement.

This text should be as concise as possible and refer only to relevant information, whilst ensuring that everything that requires consideration is included. Additional paper may be used if required.

I missed two examinations as I was in a car accident on 17 April and suffered severe whiplash and bruising to my ribs. The hospital prescribed painkillers, which made me drowsy and unable to concentrate. Due to these effects and the pain I was unable to attend the examination.

Summary of documentation

Please use the space below to list the supporting documentation submitted as part of the claim. This should include outstanding documentation to be submitted at a later date, with an expected submission date and reason for delay. Refer to the guidance notes for information on required standards of documentation.

  • Letter from the hospital
  • Copy of the police report (awaited – not yet issued by Police, and expected by 20/05/12)


I confirm that the information provided in this form, and any additional documentation relating to this request is, to the best of my knowledge, true and accurate.





Once completed, this form and all supporting documentation should be submitted to:

Your academic school will put their details here

Law, regulations and policies can change quickly. The information on our website is given in good faith and has been carefully checked but QMUL cannot accept responsibility for any errors or omissions. QMUL is not responsible for the content or reliability of the linked websites which are provided for further information.

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