Form received and checked Date: Initials: Does student have Long Term Health YES NO Condition status? (If so please attach) Previous claims (If so please attach) YES NO Is this claim self-certified? If yes check this YES NO is the first SC claim of the year (nb only 1 SC claim allowed per year) Does student have DAS status or SSD YES NO Logged on to database Date: Initials: INITIAL DECISION Date: Initials: Decision VALID INVALID Request Further Information Date: Initials: Further information received: Date: Initials: CONFIRMED DECISION Date: Initials: Decision VALID INVALID Reason for INVALID decision: EXTENDED SUBMISSION DEADLINES Module Code Original Revised Time Notes Submission Deadline Deadline Refer to DAS YES / NO Date: Initials: Send Long Term Health Condition form Date: Initials: YES / NO Fitness to study SSM required YES / NO Date: Initials: Student Notified Date: Initials: Informed Module Leaders Date: Initials: Entered onto UNITe Date: Initials: HES Only: Refer to OH YES/NO Date: Initials:
Form received and checked Date: Initials: Does student have Long Term Health Condition status? (If so please attach) YES NO Previous claims (If so please attach) YES NO Is this claim self-certified? If yes check this is the first SC claim of the year (nb only 1 SC claim allowed per year) YES NO Does student have DAS status or SSD YES NO Logged on to database Date: Initials: INITIAL DECISION Date: Initials: Decision VALID INVALID Request Further Information Date: Initials: Further information received: Date: Initials: CONFIRMED DECISION Date: Initials: Decision VALID INVALID Reason for INVALID decision: EXTENDED SUBMISSION DEADLINES Module Code Original Deadline Revised Submission Deadline Time Notes Refer to DAS YES / NO Date: Initials: Send Long Term Health Condition form YES / NO Date: Initials: Fitness to study SSM required YES / NO Date: Initials: Student Notified Date: Initials: Informed Module Leaders Date: Initials: Entered onto UNITe Date: Initials: HES Only: Refer to OH YES/NO Date: Initials:
160121_Extenuating_Circumstances_form.docx