ACADEMIC CONSIDERATION
REQUEST FORM
Academic Counselling, Science and Basic Medical Sciences | NCB 280 www.uwo.ca/sci/counselling | submit to: https://help.sci.uwo.ca/servicedesk/customer/portal/3
For ACADEMIC COUNSELLING OFFICE USE ONLY:
Record Checked:
SAS Form Given:
SPC Exam Form Given:
Denied:
By:
Additional Doc in LF?
Department/Student Notified (initial):
Date Notified:
NOTES:
V10 06/013/18
NOTE: Medical Documentation must be submitted within 2 business days of end of illness as indicated by the doctor/health care professional
Section #3: Course Components Affected by Absence
DATE:
TIME:
Course Name & Number
(ex. Biology 1001a001)
Course Component
Exam/Midterm
Conflicts Only:
CONFLICTS: Please indicate in far right column what you will be rescheduling. Please check makeup times before submitting this form.
Class
Lab
Tutorial
Assignment
Test/Quiz
Midterm
Midterm (in class)
Midterm (Special)
Final Exam
Final (Special)
Class
Lab
Tutorial
Assignment
Test/Quiz
Midterm
Midterm (in class)
Midterm (Special)
Final Exam
Final (Special)
Class
Lab
Tutorial
Assignment
Test/Quiz
Midterm
Midterm (in class)
Midterm (Special)
Final Exam
Final (Special)
Class
Lab
Tutorial
Assignment
Test/Quiz
Midterm
Midterm (in class)
Midterm (Special)
Final Exam
Final (Special)
PLEASE READ: I confirm that the information provided is complete & accurate. I understand that it is my responsibility to inform my professors as well as the Dean’s
Office about absences in a timely manner so that appropriate arrangements can be made.
Exam/Midterm Conflicts: By signing below, I confirm that the makeup to the exam/midterm I have chosen to defer does not conflict with another exam/midterm,
lab, tutorial or class.
I write with Accommodated Exams (Student Accessibility Services (SAS)): YES NO
Student Signature: _____________________________ Date: ________________________
Section #1: Student Information
Student #:
Date:
First Name:
Last Name:
Western
EMAIL:
Phone:
Section #2: Reason for Consideration/Documentation Provided
REASON:
Compassionate
Varsity
Medical/Mental Health  Other_______________
Midterm Conflict
Religious Holiday/Holy Day
DOCUMENTATION PROVIDED:
Student Medical Certificate or Other Type of Medical Note
Intercollegiate Athletics Commitment Verification Form
Other (provide details): ________________
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