REQUEST FOR SPECIAL CONSIDERATION

Division of Student Administration

Charles Sturt University CRICOS 00005F (NSW) 01947G (VIC) and 02960B (ACT)

SA-SC-0610

INSTRUCTIONS (for enrolled students) Return completed form to Student Central or Student Administration (see page 2) The purpose of this form is to allow you to advise the University that you have special circumstances which have occurred and which may affect your ability to undertake your studies or complete assessment tasks in a subject(s). For short extensions for assessment tasks that will be completed within the session, please contact your Subject Coordinator directly to determine whether this form is required. Print clearly in BLOCK LETTERS in black or blue pen to complete sections 1, 2 and 3. Please refer to section 2 below for relevant Regulations. Further information regarding the Privacy and Personal Information Protection Act 1998 (NSW) and the Health Records and Information Privacy Act 2002 (NSW) can be found at www.csu.edu.au/division/student-admin/privacy.htm .

Section 1 Personal Details

Student Number |____|____|____|____|____|____|____|____| Family Name:.............................................................. Given Name/s: ........................................................................................ Administrative Campus: ............... Course code: ............................... Course Name ...................................................................

Section 2 Students Impact Statement - I would like to request: Tick appropriate box(s) Note: Subject(s) for which Special Consideration is being requested must be listed on page 2.

To Withdraw from the subject(s) listed (an AW, FW or FL grade may be recorded). I request an Approved Withdrawal (AW) Grade After Census Date be granted. The granting of an AW after the census date does not mean that you are entitled to the automatic remission of your HECS-HELP debt, FEE-HELP debt, or tuition liability for that subject (refer Assessment Reg. 6.4 & Special Consideration Reg. 4.2)

I wish to cancel my enrolment in the above course and from Charles Sturt University

A Supplementary Exam (SX) Grade be granted (available if submitted either before the exam period or within three working days of the examination date (refer Assessment Reg. 7.2 & Special Consideration Reg. 4.6) An exemption for attendance at a compulsory residential school (only available prior to residential school dates) (refer Assessment Reg. 15.2.1 & Special Consideration Reg. 4.7) An exemption or extension from a compulsory assessment item or practical session (Special Consideration Reg 4.1) A Grade Pending (GP) grade be granted (refer Assessment Reg. 7.3 & Special Consideration Reg. 4.5) Other Special Consideration (please detail): ......................................................................................................................

The following condition affects my

Study

or

Exams Tick appropriate box(s)

(You must complete this section in your own words) Provide brief details of the circumstances

Describe the way in which the above circumstance(s) have affected you

Attach verified supporting documents (must be verified by Justice of the Peace or CSU staff member - required to be a valid application). If medical reasons apply you must include the CSU Student Medical Certificate. Signature of student ................................................................................................. Date ..................................................

Student Number:

Student Name:

Section 3 Current enrolment - subject(s) for which special consideration is being requested Student to complete:
Session Code Subject Code Campus/ Mode

Academic Staff to complete:

Subject Co-ordinators Recommendation & Signature
Recommended Grade (if applicable)

If GP Grade - School sent copy to student: ____/____/____ Grade not to be entered until 3 weeks prior to session end to allow exam notification

Section 4 - Subject Co-ordinator to complete (if applicable) I certify that at the time of the claimed misadventure, the student had completed and submitted the appropriate portion of the assessment material. Requirement for the completion of the subject ______________(please specify precisely eg Assignment 3, final examination) .................................................................................................................................................................................................... .................................................................................................................................................................................................... Time limit - date by which outstanding work must be submitted (date set must not be beyond the second week of the next Teaching session unless Assessment Regulation 7.5.1 applies) ) _____/_____/_____ The application for the subject _____________ is declined or varied for the following reasons: .................................... .................................................................................................................................................................................................... .................................................................................................................................................................................................... Subject Co-ordinator Signature.............................................................................. Section 5 Completion by Head of Teaching School (if applicable) (Not required for compulsory assessment item or practical session) Date ........................................................

Recommendation approved

Recommendation varied as follows:

Date ........................................................

.................................................................................................................................................................................................... .................................................................................................................................................................................................... Head of Teaching School Signature......................................................................

Please drop into Student Central (Ph: 1800 275 278), or fax (02) 6338 6599, or post to Student Administration Office at your home campus, or scan and email to your Liaison Officer at Student Administration (originals will still need to be verified): Albury-Wodonga Bathurst Wagga Wagga Orange Student Administration Student Administration Student Administration Student Administration Charles Sturt University Charles Sturt University Charles Sturt University Charles Sturt University PO Box 1268 Private Mailbag 7 Locked Bag 588 PO Box 883 ALBURY NSW 2640 BATHURST NSW 2795 WAGGA WAGGA NSW 2678 ORANGE NSW 2800 Student Administration Office Use: Authorised: Entered: Checked: Please Return To: Campus: Student notified:

Page 2

SA-SC-0610

STUDENT MEDICAL CERTIFICATE

Division of Student Administration
Charles Sturt University CRICOS 00005F (NSW) 01947G (VIC) and 02960B (ACT)

INSTRUCTIONS: This form is used for applying for special consideration on medical grounds for examinations or other assessable work/studies (Special Consideration Regulations 5.1) or in other instances where a medical certificate may be required. Students are required to complete Section 1 and give this form to their Medical Practitioner or Health Care Provider to complete Section 2 and have the providers stamp affixed. When completed, this document may be submitted as an evidentiary document with the Special Consideration form. For further information, please refer to the Special Consideration Regulations located at: http://www.csu.edu.au/acad_sec/regulations.htm Section 1. Student Details Student Name Student number

I authorise CSU to contact the medical practitioner to provide further details to CSU in order to discuss and verify the implications of the illness/condition of which I am suffering. Signature: ........................................................................... Date: ...........................................................................

Section 2. Medical Practitioner / Health Care Provider (Special Consideration Regulations 5.1.4) Name of Practitioner Provider Number Address Contact Telephone(s) Date of attendance I certify that Is unfit for studies This illness would (please tick) from D D / M D D / M M / Y M Y / Y Y Y Y Time Y Y to D D / M M / Y Y Y Y PATIENTS NAME PROVIDERS STAMP or Practitioner Number Must be affixed here

Severely affect Moderately affect Slightly affect Not affect

The patients capacity to

Attend classes Participate in fieldwork Complete assignments Sit examinations

I am unable to assess how this illness would affect the patients capacity My assessment of the patients condition was based on: An examination of the patient Information provided by the patient

Within the limits of patient confidentiality, please state the nature of the problem/illness/difficulty experienced by the patient over this period. ............................................................................................................................................................................................... ............................................................................................................................................................................................... Practitioners signature PRACTITIONERS SIGNATURE Date D D / M M / Y Y Y Y

Privacy & Health The personal information you provide on this form to Charles Sturt University (CSU) is governed by the Privacy and Personal Information Protection Act 1998 (NSW) and Health Records and Information Privacy Act 2002 (NSW). The personal information you provide will not be made available to any other person or organisation outside of the University or for any other purpose without your consent or where authorised by law, and will be disposed of in accordance with Government regulation. If you are unhappy with the way we have handled or failed to handle your personal information you may apply to have the matter reviewed by lodging a formal application to the University Secretary whose address is, The University Secretary, Charles Sturt University, The Grange, Panorama Ave Bathurst, NSW Australia 2795

SA-SMC-0309