Before completing this form please refer to and the notes overleaf for information regarding
requesting an extension. Please make sure that an extension is suitable for your circumstances. If you feel that your
performance will still be impacted by your circumstances, even with additional time, you should consider deferring the
assessment. See When completing this form you should ensure that you enclose supporting evidence.
You must submit the completed form to the Sub-Board Chair responsible for your assessment.
Last updated January 2020
Continued Overleaf
Section 1: Your Details (please print in block capitals)
Family Name First name(s)
Student ID Number (e.g. 201312345) Programme of Study (e.g. BSc Economics)
Section 3: Reason for Application
Please provide a brief explanation of why you are applying for an extension. Your circumstances must be sudden,
unforeseen, out of your control and proximate to the assessment(s) in question. Please continue on a separate sheet if
necessary. If you are able to provide any supporting evidence with this request, please list it here.
Section 2: Assessments that you are unable to submit by the original deadline
IMPORTANT: You may list more than one piece of work if the circumstances are proximate to all of the submission
deadlines. However, you may also need to consider deferring your assessment or interrupting your studies.
Course Code Unit Value Type of Assessment Due Date Weighting
(e.g. AC100) (e.g. 1.0 or 0.5) (e.g. LT 5,000 word essay) (e.g. 13.10.2019) (e.g. 30% of overall course mark)
No. of extra
days required
(e.g. 1-10)
Please visit for further information about extensions.
If you have a visa please visit the Immigration Advice webpage for more details of how an
extension may impact on your immigration permission.
You must submit your extension request in advance of the assessment deadline.
Once completed; the form and evidence should be submitted to the Sub-Board Chair of the
Department responsible for the assessment (scanned copies submitted by e-mail are acceptable).
NB. Some Departments may delegate the Course Convenor or other individual
If you submit the assessment late after either the original deadline or new extended deadline, late
mark penalties will be applied.
Details of the outcome of your request will be sent to your LSE e-mail address. You must not
assume your request has been approved until you receive a confirmation e-mail.
If you have an Inclusion Plan that includes allowing for the possibility of extensions, you should liaise
directly with your Department as you may not need to submit a form for each extension request.
If your request is not approved and you do not submit the assessment you will receive a zero mark
for that assessment.
Name Signature Date
By signing this section of the form you confirm that you have reviewed and are satisfied with the information provided.
You also confirm that you support this request. Please indicate the new extension date and time in the box below:
Submission Time
New Submission Date
Section 4: Student Declaration
By signing this form you confirm that you have read the guidance provided. If you are unable to provide evidence, you
also confirm that you have provided a true and honest account of your circumstances. You understand that once you
submit work you have declared yourself fit to do so. If you require a visa to study at LSE, you understand that if this
extension exceeds the validity of your visa you may need additional immigration permission and you have sought advice
from the International Student Visa Advice Team (ISVAT).
Section 5: Approval
For completion by the Sub-Board Chair responsible for the course to which the assessment belongs. This section must be
completed before the form is returned to Programme Administrator.